24. Characteristics of labor and delivery Definitions Instructions Sources Key words/Abbreviations g - Clinical chorioamnionitis Check that recorded maternal 1st Delivery Record under: Chorioamnionitis Maternal OB/labor Chorio temperature is at or above 38°C Diagnosed during labor or summary Amnionitis (100.4°F). – comments/complications IUI (intrauterine infection) maternal temperature greater than Labor summary record Temp > 38 or 100.4 or equal to 38°C (100.4°F). Look for: Clinical diagnosis of 2nd Newborn Admission H&P Maternal fever chorioamnionitis during labor Mother febrile made by the delivery attendant. 3rd Physician Progress Note Usually includes more than one of 4th Maternal Vital Signs Record the following: fever, uterine under: tenderness and/or irritability, Temperature Recordings leukocytosis, or fetal tachycardia. Any recorded maternal temperature at or above 38°C (100.4°F). 1st Delivery Record under Mec Meconium h - Moderate or heavy – Maternal OB/labor meconium staining of the amniotic fluid summary Staining of the amniotic fluid Labor summary record caused by passage of fetal bowel Amniotic fluid summary contents during labor and/or at delivery that is more than enough section color – to cause a greenish color change Time membranes ruptured section of an otherwise clear fluid. 2nd Newborn Admission H&P 3rd Physician Progress Note
24. Characteristics of labor and delivery Definitions Instructions Sources Key words/Abbreviations g - Clinical chorioamnionitis Diagnosed during labor or maternal temperature greater than or equal to 38°C (100.4°F). Clinical diagnosis of chorioamnionitis during labor made by the delivery attendant. Usually includes more than one of the following: fever, uterine tenderness and/or irritability, leukocytosis, or fetal tachycardia. Any recorded maternal temperature at or above 38°C (100.4°F). Check that recorded maternal temperature is at or above 38°C (100.4°F). 1st Delivery Record under: Maternal OB/labor summary – comments/complications Labor summary record 2nd Newborn Admission H&P 3rd Physician Progress Note 4th Maternal Vital Signs Record under: Temperature Recordings Chorioamnionitis Chorio Amnionitis IUI (intrauterine infection) Temp > 38 or 100.4 Look for: Maternal fever Mother febrile h - Moderate or heavy meconium staining of the amniotic fluid Staining of the amniotic fluid caused by passage of fetal bowel contents during labor and/or at delivery that is more than enough to cause a greenish color change of an otherwise clear fluid. 1st Delivery Record under Maternal OB/labor summary Labor summary record Amniotic fluid summary section – color Time membranes ruptured section 2nd Newborn Admission H&P 3rd Physician Progress Note Mec – Meconium