Date
Patient: (Name, Gravida, Parity, Estimated Gestational Age [EGA])
Chief Complaint: (Describe presenting symptoms, e.g., contractions, cramping, vaginal bleeding)
History of Present Illness:
Onset and duration of symptoms (contractions, frequency, duration, intensity)
Associated vaginal bleeding or leakage of fluid
Previous episodes of preterm labor or cervical insufficiency
Risk factors for preterm labor (e.g., prior preterm birth, uterine anomalies, infections)
Prenatal care compliance
Physical Exam:
Vital signs (temperature, blood pressure, heart rate) – elevated temperature may suggest infection
General (fetal movement, signs of infection)
Abdominal exam (uterine tenderness, fundal height)
Pelvic exam (cervical dilation, effacement, station, presence of membranes)
Fetal Assessment:
Fetal heart rate monitoring (non-stress test or tocography) – to assess fetal well-being
Laboratory Tests:
Complete blood count (CBC) – may show signs of infection (elevated white blood cells)
Fibronectin test (optional) – may be used to assess risk of preterm delivery within the next 7 days (positive test suggests increased risk)
Cervical swab for cultures (if indicated) – to rule out infections
Assessment:
Preterm labor (confirmed by presence of regular contractions and cervical changes)
Gestational age at presentation
Severity of preterm labor (threatened, imminent, established) – based on cervical changes and contraction frequency
Risk factors for preterm delivery and potential causes of preterm labor (if identifiable)
Plan:
Management plan based on gestational age, severity of labor, and fetal assessment:
Expectant management: for some cases of threatened preterm labor with reassuring fetal status.
Tocolytic therapy: medications to suppress contractions (if indicated).
Corticosteroids: to accelerate fetal lung maturity (if gestational age appropriate).
Antibiotics: if infection is suspected.
Delivery planning (vaginal or cesarean) – may be necessary depending on the situation.
Education:
Explain preterm labor, its risks, and the planned management approach.
Discuss the importance of rest, hydration, and monitoring fetal movement.
Warning signs and symptoms to watch for (worsening contractions, vaginal bleeding, fever) that may indicate progression of labor or infection.
Follow-up:
Schedule for follow-up appointments:
Monitor for changes in cervical status and contractions.
Assess fetal well-being.
Adjust management plan as needed.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of preterm labor