Vital Signs

(Unless otherwise ordered)

Antepartum (Non-Laboring) - HR, BP, RR,

SpO2
With intermittent fetal monitoring - q4HR
With CEFM - q1HR

Temperature
Q4HR - Intact membranes
Q2HR - Rupture of Membranes has occurred

Intrapartum Pt, w/o augmentation or epidural

Latent Phase, Stage 1 Labor
Assess/Document maternal HR, BP, SpO2
at least q1HR; RR at least q1HR
Active Phase, Stage 1 Labor
Assess/Document maternal HR, BP, SpO2
at least 30 minutes; RR at least q1HR
Stage 2 & Stage 3
Assess/Document maternal HR, BP, SpO2
at least 15 minutes; RR at least q1HR

Vital Signs
(Unless otherwise ordered)

Intrapartum Pt, w/ augmentation or epidural

Pt with an epidural, refer to Lippincott: Epidural anesthesia, care during labor
Patient with induction/augmentation, refer to
Oxytocin and Augmentation of Labor Protocol
For pt with induction/augmentation using cervical ripening agents
At least q1HR in latent phase, stage 1 labor
At least q30min in active phase, stage 1
labor
At least q15min in stage 2 labor
Pts on Magnesium Sulfate, refer to Lippincott:
Magnesium Sufate Administration
Pts with intravenous Patient Controlled Anesthesia with Opieods (PCA), refer to Lippincott
Patient-Controlled Analgesia, Adult and Pediatric PatientsTUKH

Vital Signs
(Unless otherwise ordered)

All Patients
Notify the physician of any deterioration in the
patients condition and document
Increase the frequency of vital signs and assessments as indicated by the patients condition

Vital Signs
(Unless otherwise ordered)
Definitions:
Antepartum Patient: A pregnant patient
Non-Laboring Patient: A pregnant woman without objective signs of labor
Laboring Patient: A patient who is experiencing
progressive cervical change
Intrapartum Patient: A patient being cared for
during the labor process
Labor Induction: agents used to stimulate or effect labor (contractions)
Labor Augmentation: agents used to assist or
strengthen existing labor
Rupture of Membranes: loss of integrity of the
amniotic membranes resulting in a loss of amniotic
fluid
Intact Membranes: no interruptions of the amniotic membranes
Cervical Ripening Agent: agents used to effect
remodeling of the cervix involving connective tissue changes which allow for cervical readiness for
dilation and effacement with contractions.

Vital Signs
(Unless otherwise ordered)

Labor Latent Phase, Stage 1: early phase of the

1st stage of labor (<6 cm) where contractions are
effecting slow cervical dilation
Labor Active Phase, Stage 1: phase of the 1st
stage of labor (6 cm-10 cm) where dilation and effacement are accelerating
Labor Pushing, Stage 2: The second stage begins
when cervical dilatation is complete and ends with
the delivery of the infant.
Stage 3: The third stage begins immediately after
delivery of the fetus and ends with the delivery of
the placenta.
Electronic Fetal Monitor: An electrophysiological monitoring system that communicates fetal
heart rate and uterine activity (contraction) information to a recording system