Laboring Note

LABOR NOTE

[]-year-old G[]P[] at [] []/7 wga admitted [in spontaneous labor][for induction].

S: Patient resting comfortably in bed[ with epidural]. No major complaints.

O:

[insert vital signs]

Physical exam

Gen: no apparent distress

Pulm: normal effort of breathing

CV: warm and well-perfused

Abd: soft, nontender, nondistended

Uterus: gravid

Ext: trace edema

Neuro: alert & oriented x 3

Membrane: [intact][ruptured]

Cervix: []/[]/[], [position]

FHT: baseline [], [moderate] variability, []accelerations present, [no] decelerations

Toco: q[] ctx

Assessment and Plan:

[]-year-old G[]P[] at [] []/7 wga admitted [in spontaneous labor][for induction]. Progressing in labor[ with adequate pain control].

- Continue [] and []

- Continue fetal heart rate monitoring and contraction monitoring

- Repeat cervical exam in [] hours or as clinically indicated.

- Attending physician [] updated on patient's status by HO [].