Documentation Guidelines

• Time of ROM, color of fluid, amount of fluid, presence of any odor

• Contractions: Frequency, duration, intensity, pattern, patient's response

• FHR assessment: Baseline, accelerations, decelerations, variability

• Patient's comfort level in labor, response to medications, vital signs

• Signs and symptoms of infection: Elevated maternal heart rate and temperature; malodorous amniotic vaginal discharge/fluid; fetal tachycardia

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