Documentation Guidelines

• Progress in labor: Cervical effacement and dilation, station of fetal head, presence of molding or caput, contraction pattern

• Factors contributing to FPD: Pelvic size and shape; fetal presentation, position, and attitude; maternal position; bladder and bowel fullness; duration, frequency, and strength of contractions

• Indicators of fetal well-being: Fetal baseline heart rate, variability, presence of accelerations and decelerations; fetal activity level; response to scalp stimulation

• Indicators of maternal well-being: Tolerability of labor pain, effectiveness of coping strategies, presence of support people, indicators of psychological status, vital signs

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