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Obstetric & Perinatal Nursing Communication

Maternity & Labor and Delivery (L&D) SBAR Template

Designed for obstetric triage, labor and delivery handoffs, postpartum maternal deterioration, and perinatal emergency escalation. Built around dual-patient evaluation (mother and fetus) and standardized NICHD fetal monitoring criteria.

Why Obstetric & Perinatal SBAR Communication Differs

Perinatal nursing is unique because every clinical interaction involves at least two patients: the mother and the fetus. Communication must capture rapid obstetric dynamics and standardized nomenclature:

1. Obstetric Demographics & Gestational Age:Gravida/Para (G/P, TPAL), exact Gestational Age (GA in weeks + days), Group B Strep (GBS) status, Rh factor, and prenatal risk factors (gestational diabetes, preeclampsia, previous C-section).
2. Fetal Monitoring via NICHD Categories:Mandatory standardized terminology: baseline FHR, variability (moderate, minimal, absent), accelerations, decelerations (early, late, variable, prolonged), and NICHD Category (I, II, or III).
3. Membrane & Labor Progress Metrics:Rupture of Membranes (ROM) duration and fluid clarity (clear, bloody, meconium), contraction frequency/duration/intensity, and cervical exam (dilation cm / effacement % / fetal station).
4. Obstetric Emergencies & High-Risk Medications:Maternal severe hypertension (BP ≥ 160/110), postpartum hemorrhage quantitative blood loss (QBL), and titration of high-alert infusions (Oxytocin / Pitocin, Magnesium Sulfate).

Maternity & L&D SBAR Clinical Worksheet (Blank)

Standardized layout for labor handoffs, obstetric provider alerts, and fetal tracing escalations.

Patient: ____________________
Age / Bed: ____________________
G / P (TPAL): ____________________
Gestational Age: ____ wks ____ days
SSITUATION — Acute Obstetric / Perinatal Trigger

Identify primary acute concern: Category II/III fetal tracing, severe range hypertension, postpartum hemorrhage, cord prolapse, or rapid labor progression.

Primary Concern: [ ] Fetal Heart Rate Deterioration   [ ] Severe Pre-Eclampsia   [ ] Hemorrhage / QBL   [ ] Labor Arrest   [ ] Cord Prolapse

Current Stage of Labor: [ ] Triage [ ] Stage 1 (Latent/Active) [ ] Stage 2 (Pushing) [ ] Stage 3/Postpartum

Urgency Level: [ ] Emergent (immediate bedside)   [ ] Urgent (within 15 min)   [ ] Informational/Orders

BBACKGROUND — Prenatal History, Labs, & Labor Course

Prenatal risk factors, GBS status, membrane status (ROM), anesthesia/analgesia, current infusions, and allergies.

Obstetric History & Comorbidities: GBS: [ ] Pos [ ] Neg [ ] Unk | Rh: [ ] Pos [ ] Neg | [ ] Prior C/S [ ] GDM [ ] Chronic HTN

Membranes: [ ] Intact   [ ] SROM / AROM at (time): _________ | Fluid: [ ] Clear [ ] Meconium (light/thick) [ ] Bloody

Active Infusions / Meds: Oxytocin: _____ mU/min | Magnesium Sulfate: _____ g/hr | Epidural: [ ] Yes [ ] None

Allergies: ____________________________________________________________________________________

AASSESSMENT — Fetal Monitoring, Cervical Exam, & Maternal Vitals

FHR baseline, variability, decelerations, NICHD category, uterine activity, cervical exam, and maternal vital signs.

Fetal Heart Rate (FHR): Baseline: _____ bpm | Variability: [ ] Mod [ ] Min [ ] Absent | Decels: [ ] None [ ] Early [ ] Variable [ ] Late [ ] Prolonged

NICHD Fetal Tracing Category: [ ] Category I (Normal)   [ ] Category II (Indeterminate)   [ ] Category III (Abnormal)

Contraction Pattern: Frequency: every ____ min | Duration: ____ sec | Resting tone: [ ] Soft [ ] Hypertonic / Tachysystole

Cervical Exam: Dilation: _____ cm | Effacement: _____% | Station: _____ | Presenting part: [ ] Vertex [ ] Breech

Maternal Vitals: BP: _____/_____ | HR: _____ | Temp: _____°F | SpO2: _____% | Pain: _____/10 | Bleeding / QBL: _____ mL

Intrauterine Resuscitation Initiated: [ ] Reposition (left/right lateral) [ ] IV fluid bolus [ ] O2 applied [ ] Oxytocin stopped [ ] Terbutaline given

RRECOMMENDATION — Obstetric Action & Delivery Plan

Specific request for bedside physician exam, IUPC/FSE placement, amnioinfusion, stat antihypertensive, or emergency operative delivery.

Requested Action: [ ] Immediate bedside physician evaluation   [ ] Place FSE / IUPC   [ ] Emergency C-Section / Operative Delivery   [ ] Antihypertensive Order

Specific Medication / Order: __________________________________________________________________

NICU / Anesthesia Alerted: [ ] Yes [ ] Pending confirmation

Fictional Scenario

Maternity Escalation Example: Category II Fetal Tracing & Tachysystole

Scenario: A 28-year-old Primigravida at 39 weeks 2 days gestation in active labor on Oxytocin induction develops uterine tachysystole with recurrent late decelerations and minimal variability.

S Situation

"Dr. Patel, this is Jessica, RN in L&D Room 4 calling regarding patient Maya T., a 28-year-old G1P0 at 39 weeks 2 days. The fetal heart rate tracing has deteriorated to Category II with recurrent late decelerations and minimal variability following uterine tachysystole over the last 15 minutes."

B Background

"She was admitted this morning for elective induction of labor. GBS negative, Rh positive, uncomplicated prenatal course. AROM was performed 3 hours ago with clear amniotic fluid. She has a functioning labor epidural with good pain control. She was on Oxytocin at 12 mU/min. No known drug allergies."

A Assessment

"The fetal heart rate baseline is 145 bpm with minimal variability (less than 5 bpm) and recurrent late decelerations dropping to 105 bpm lasting 45 seconds after each contraction. The toco showed tachysystole with 6 contractions in a 10-minute window. Cervical exam 10 minutes ago was 6 cm dilation, 80% effacement, -1 station. Intrauterine resuscitation interventions completed: Oxytocin infusion turned completely off, repositioned patient to left lateral position, administered 500 mL IV Lactated Ringer's bolus, and applied non-rebreather mask at 10 L/min. Maternal vitals: BP 118/74, HR 82 bpm, Temp 98.6°F, SpO2 99%."

R Recommendation

"I request that you come to the bedside to evaluate the fetal tracing. If the decelerations persist despite turning off Oxytocin and position changes, I recommend an order for Terbutaline 0.25 mg SQ for tocolysis, and placing a Fetal Scalp Electrode (FSE) and Intrauterine Pressure Catheter (IUPC) for direct monitoring."

Looking for labor & delivery and fetal monitoring SBAR examples?Explore Maternity & Fetal Heart Tracing Example on SBAR Examples →

Authoritative Obstetric & Perinatal Sources

  • American College of Obstetricians and Gynecologists (ACOG): Practice Bulletin No. 106 – Intrapartum Fetal Heart Rate Monitoring & NICHD Three-Tier Classification.
  • Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN): Standards for Professional Nursing Practice in the Care of Women and Newborns.
  • The Joint Commission (TJC): Sentinel Event Alert – Preventing Maternal Death and Morbidity through Standardized Obstetric Communication.