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Evaluation of labor

OB

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#Evaluation of labor, term - Reports contractions q***min starting at ***. Denies*** LOF, VB. Endorses*** good fetal movement. She {DESC; REPORTS/DENIES:21568} a history of rapid labor.
- SSE {DESC; WITH/WITHOUT:18785} evidence of rupture
- Toco {DESC; WITH/WITHOUT:18785} regular contractions
- SVE ***/***/***
Option 1:***
- The patient was not having regular contractions (at least every 5-7 minutes) and is dilated < 3cm.  She was discharged home with labor precautions.***

Option 2:***
- The patient is having regular contractions and is dilated 2-4 cm.  We recommend repeat cervical exam in 1-2 hours to assess cervical change.  We encouraged the patient to walk around during this time period.***

Option 3:***
-  The patient is having regular contractions and is dilated >5 cm. Plan to admit to L&D.***

# FWB
- NST: {reactive/ non reactive/ unknown:24043}
- GBS: {status; positive negative unknown:34698}

Yellow *** markers = placeholders you fill in or delete per case.

Hannah Kelly, MD (compiled from prior Duke residents) · last reviewed 2026-07