Admit DR (Active Labor)
- Confirm active labor: regular painful contractions + cervical dilatation ≥4 cm + effacement; distinguish from latent phase
- GA at admission — term (37-41+6 wk), preterm (<37 wk), post-term (>42 wk)
- Labor stage: 1st stage (latent 0-4 cm, active 4-10 cm), 2nd stage (10 cm to delivery), 3rd stage (placenta)
- GBS status: ถ้า positive → Penicillin G IV; ถ้า unknown + risk factors (fever, ROM >18h) → ให้ ATB
- Fetal presentation: vertex (normal), breech → C/S consideration
- SROM (spontaneous rupture of membranes): ถ้า >18h = PROM infection risk; Ferning + pooling + pH >6.5 confirm
- Maternal vital signs: BP q30-60 min; fever = chorioamnionitis concern
🕐 One-Day Orders
🔬 Investigation
- CBC — Hb baseline + WBC (infection/chorioamnionitis)
- Blood group + ABO/Rh ถ้ายังไม่ทราบ
- Urine dipstick — protein (pre-eclampsia), glucose, nitrite
- FBS/RBS ถ้า GDM/DM
- Vaginal swab for GBS ถ้าไม่ทราบสถานะ
- CTG (Cardiotocography) — FHR + contraction monitoring: admit strip 20 min → continuous ถ้า high-risk
- Internal examination (IE) — cervical dilatation, effacement, station, presentation, position q4h (active phase)
💊 Medication
- IV NSS lock (หรือ 5%DW NSS KVO) — IV access; เตรียม epidural/resuscitation
- NPO (soft diet allowed latent phase; clear liquid/ice chips active phase)
- [GBS positive หรือ ROM >18h + risk:]: Penicillin G 5 MU IV เพราะ labor → 2.5 MU IV q4h จนคลอด; ถ้า PCN allergy: Cefazolin 2 g IV loading → 1 g q8h
- Oxytocin augmentation ถ้า inadequate contractions (เห็น OB ผู้ดูแลก่อน):
- Syntocinon (oxytocin) 5 IU in 5%DW 500 mL; start 2 mU/min, เพิ่ม q30 min
- Epidural analgesia — per patient request + anesthesia consult
🔁 Continuous Orders
🔬 Investigation
- CTG continuous ถ้า high-risk / epidural / oxytocin
- IE q4h (active phase) — progress หรือ ช้ากว่า 1.2 cm/h (nullipara) = protracted/arrested labor
- Maternal vital signs q30-60 min (BP, HR, temp q4h)
💊 Medication
- [Chorioamnionitis]: Ampicillin 2 g IV q6h + Gentamicin 1.5 mg/kg IV q8h — เริ่มทันทีถ้า temp >38°C x2 หรือ >38.5°C x1 + uterine tenderness/fetal tachycardia
- [Preterm labor <34 wk]:
- Tocolysis: Nifedipine 20 mg PO → 10-20 mg q6h (48h) — เพื่อให้เวลา steroids
- Betamethasone 12 mg IM q24h x2 doses (ถ้า GA 24-34 wk)
- 3rd stage management: Syntocinon 10 IU IM หลัง delivery — reduce PPH; หรือ Carbetocin 100 mcg IM ถ้า C/S