Ocean County College School of Nursing
Student Labor and Delivery Observation - Student name:
Initial student observation: stage/ phase of labor or c-sect Concluding student observation stage/ phase of labor or c-
First stage – latent phase sect
First stage – latent phase
Pt initials KB Pt age 31 Allergies NKA Date of Care 9/30/25
Prenatal Care? Yes Gravida/Para G1P1 TPAL 0 Gestation 41w5d
Medical History/OB History/Risk Factors
Polycystic ovarian syndrome, ADHD, GBS-, version successful
Maternal Assessment on admission (locate information in chart if pt admitted prior to clinical)
Time mother reports labor began (vaginal only) Time of admission to labor unit 9/29/25 at 1830
Cervical dilation (cm) 1cm Cervical effacement (%) 50%
Fetal presentation cephalic Fetal position vertex Station -3
Membranes (intact or ruptured) intact SROM time n/a Amniotic fluid color n/a
Labor stage & phase on adm first stage – latent phase Support person? Husband at bedside
First Stage of Labor (if applicable document for vaginal delivery. For Scheduled C-Sections skip to next section)
Progression of cervical dilation during clinical (cm) 3cm Progression of cervical effacement (%) 50%
Membranes ruptured SROM AROM n/a ROM time n/a Amniotic fluid color n/a
VS: T P R B/P sPO2 Pain FHR
Time(s):
0830 97.9 65 16 120/79 99% 3/10 Baseline 130-140bpm,
moderate variability,
no decels noted
Progression of contractions Frequency Duration Intensity
Time(s):
0830 Q6-8min 30-45 sec Mild by palpation
1000 Q4-6min 45-60 sec Mild-moderate by palpation
1200 Q3-5min 45-60 sec Moderate, tolerated well w/
epidural
Scheduled Cesarean Sections and Vaginal Deliveries:
FHM? External or internal
External
Decelerations? Deceleration Treatment:
None n/a
Maternal: Diet IVF & site Foley
Regular initially then no food when RT antecubital fossa In place
epidural placed
Maternal activity/safety issues
Epidural
1
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, Describe procedures initiated
Cervical ripening with Cytotec, balloon catheter placed for mechanical dilation. Cervidil used previously, failed; induction
restarted with Cytotec + balloon.
Assessments of fetal well-being
Continuous external monitoring, reassuring Cat I tracing. No decelerations observed.
Describe the mother’s behavior (labor, ability to cope with uterine contractions, support of significant other).
Calm, coping well with mild contractions, epidural in place providing comfort. Support person attentive and present.
Patient resting comfortably in bed.
Describe your observations of the woman experiencing the first stage of labor.
The patient remained in the latent phase of the first stage of labor with a balloon catheter in place and a cytotec
induction in progress. She was comfortable with her epidural but became tearful at times when discussing the overall
outlook of her delivery. She expressed feelings of frustration and concern about the length of the induction process and
the uncertainty of how her labor would progress. The patient was very apologetic for becoming emotional, and both
staff and support persons offered reassurance and emotional support. She responded positively to encouragement and
emotional support. She responded positively to encouragement and was able to rest between contractions.
Any pertinent labs, ultrasounds or diagnostic testing with results
(ie: RH status, Blood type, GBS, H+H, Biophysical Profile, Non-stress test, CBC, Amniotic fluid, FHR, Blood glucose, Urine
Protein/Ketones)
Blood Type & Rh: A positive
Antibody screen: negative
GBS: negative
Hgb/Hct: WNL
Platelets: WNL
Urine Protein: positive (continued monitoring for preeclampsia S/S)
Urine Ketones: negative
Glucose: not indicated; patient not diabetic
NST: reactive prior to induction
Amniotic Fluid: Membranes intact; no fluid noted yet
BPP/US: version previously successful, otherwise reassuring
Drug Screen: negative
2
This study source was downloaded by 100000900706475 from CourseHero.com on 10-07-2025 22:21:39 GMT -05:00
https://www.coursehero.com/file/251942673/KB-Student-Labor-and-Delivery-Formdocx/
Student Labor and Delivery Observation - Student name:
Initial student observation: stage/ phase of labor or c-sect Concluding student observation stage/ phase of labor or c-
First stage – latent phase sect
First stage – latent phase
Pt initials KB Pt age 31 Allergies NKA Date of Care 9/30/25
Prenatal Care? Yes Gravida/Para G1P1 TPAL 0 Gestation 41w5d
Medical History/OB History/Risk Factors
Polycystic ovarian syndrome, ADHD, GBS-, version successful
Maternal Assessment on admission (locate information in chart if pt admitted prior to clinical)
Time mother reports labor began (vaginal only) Time of admission to labor unit 9/29/25 at 1830
Cervical dilation (cm) 1cm Cervical effacement (%) 50%
Fetal presentation cephalic Fetal position vertex Station -3
Membranes (intact or ruptured) intact SROM time n/a Amniotic fluid color n/a
Labor stage & phase on adm first stage – latent phase Support person? Husband at bedside
First Stage of Labor (if applicable document for vaginal delivery. For Scheduled C-Sections skip to next section)
Progression of cervical dilation during clinical (cm) 3cm Progression of cervical effacement (%) 50%
Membranes ruptured SROM AROM n/a ROM time n/a Amniotic fluid color n/a
VS: T P R B/P sPO2 Pain FHR
Time(s):
0830 97.9 65 16 120/79 99% 3/10 Baseline 130-140bpm,
moderate variability,
no decels noted
Progression of contractions Frequency Duration Intensity
Time(s):
0830 Q6-8min 30-45 sec Mild by palpation
1000 Q4-6min 45-60 sec Mild-moderate by palpation
1200 Q3-5min 45-60 sec Moderate, tolerated well w/
epidural
Scheduled Cesarean Sections and Vaginal Deliveries:
FHM? External or internal
External
Decelerations? Deceleration Treatment:
None n/a
Maternal: Diet IVF & site Foley
Regular initially then no food when RT antecubital fossa In place
epidural placed
Maternal activity/safety issues
Epidural
1
This study source was downloaded by 100000900706475 from CourseHero.com on 10-07-2025 22:21:39 GMT -05:00
https://www.coursehero.com/file/251942673/KB-Student-Labor-and-Delivery-Formdocx/
, Describe procedures initiated
Cervical ripening with Cytotec, balloon catheter placed for mechanical dilation. Cervidil used previously, failed; induction
restarted with Cytotec + balloon.
Assessments of fetal well-being
Continuous external monitoring, reassuring Cat I tracing. No decelerations observed.
Describe the mother’s behavior (labor, ability to cope with uterine contractions, support of significant other).
Calm, coping well with mild contractions, epidural in place providing comfort. Support person attentive and present.
Patient resting comfortably in bed.
Describe your observations of the woman experiencing the first stage of labor.
The patient remained in the latent phase of the first stage of labor with a balloon catheter in place and a cytotec
induction in progress. She was comfortable with her epidural but became tearful at times when discussing the overall
outlook of her delivery. She expressed feelings of frustration and concern about the length of the induction process and
the uncertainty of how her labor would progress. The patient was very apologetic for becoming emotional, and both
staff and support persons offered reassurance and emotional support. She responded positively to encouragement and
emotional support. She responded positively to encouragement and was able to rest between contractions.
Any pertinent labs, ultrasounds or diagnostic testing with results
(ie: RH status, Blood type, GBS, H+H, Biophysical Profile, Non-stress test, CBC, Amniotic fluid, FHR, Blood glucose, Urine
Protein/Ketones)
Blood Type & Rh: A positive
Antibody screen: negative
GBS: negative
Hgb/Hct: WNL
Platelets: WNL
Urine Protein: positive (continued monitoring for preeclampsia S/S)
Urine Ketones: negative
Glucose: not indicated; patient not diabetic
NST: reactive prior to induction
Amniotic Fluid: Membranes intact; no fluid noted yet
BPP/US: version previously successful, otherwise reassuring
Drug Screen: negative
2
This study source was downloaded by 100000900706475 from CourseHero.com on 10-07-2025 22:21:39 GMT -05:00
https://www.coursehero.com/file/251942673/KB-Student-Labor-and-Delivery-Formdocx/
