Wiki DX for Latent labor

[dbolivar1]

I'm needing help what dx to use for Latent labor? or what should I look for. The area I work is in OB Triage.
I've found to use O62.0 Primary inadequate contractions but then I've been told to use O63.0 Prolonged first stage (of labor) (I was told to use O63.0 on Example 2). I have three examples below where provider documents to be latent labor.

Example 1:
38w0d
- Cervical exam unchanged since triage visit two days ago. In latent labor. Reactive and reassuring NST.
- Reviewed return precautions
- Morphine 15 IM; Vistaril 100 mg for pain control and help w/ sleep
Cervical Exam: 0/1/-3

Example 2:
36w6d
#Latent labor
- SVE: 1/50/-2. Exam unchanged 2 hours after re-checking.
- Comfort measures given; recommended pt go home and eat and stay hydrated. Bath/shower, rest, and distraction during early labor.
- Precautions and FKC reviewed.
- To return with increased frequency/intensity UCs, LOF, VB, decreased FM.
- Has f/u PNV on XX/XX/XX
- Discharged home in stable condition.

Example 3:
37wks 1day
Patient evaluated. Her contractions are mild.
-She has normal vitals including blood pressure
-She has no concerning symptoms (no vaginal bleeding, LOF, normal movement) and her physical exam is normal
-Negative SROM exam
-She has a reactive NST. SVE was 1/20/-2
-Her ultrasound shows fetus in cephalic position, normal placenta and fluid.
-Patient is in latent labor and has not ruptured membranes


TIA!

 

[nielynco]

I'm needing help what dx to use for Latent labor? or what should I look for. The area I work is in OB Triage.
I've found to use O62.0 Primary inadequate contractions but then I've been told to use O63.0 Prolonged first stage (of labor) (I was told to use O63.0 on Example 2). I have three examples below where provider documents to be latent labor.

Example 1:
38w0d
- Cervical exam unchanged since triage visit two days ago. In latent labor. Reactive and reassuring NST.
- Reviewed return precautions
- Morphine 15 IM; Vistaril 100 mg for pain control and help w/ sleep
Cervical Exam: 0/1/-3

Example 2:
36w6d
#Latent labor
- SVE: 1/50/-2. Exam unchanged 2 hours after re-checking.
- Comfort measures given; recommended pt go home and eat and stay hydrated. Bath/shower, rest, and distraction during early labor.
- Precautions and FKC reviewed.
- To return with increased frequency/intensity UCs, LOF, VB, decreased FM.
- Has f/u PNV on XX/XX/XX
- Discharged home in stable condition.

Example 3:
37wks 1day
Patient evaluated. Her contractions are mild.
-She has normal vitals including blood pressure
-She has no concerning symptoms (no vaginal bleeding, LOF, normal movement) and her physical exam is normal
-Negative SROM exam
-She has a reactive NST. SVE was 1/20/-2
-Her ultrasound shows fetus in cephalic position, normal placenta and fluid.
-Patient is in latent labor and has not ruptured membranes


TIA!

Always an issue when it is latent labor which can likened to the uterus trying to get the hang of being in labor (which is of course not false labor). As to the use of O63.0, I was always taught that the first stage of labor is considered to be prolonged if the early (latent) phase takes more than 20 hours for a first time mother and more than 14 hours for a woman with previous deliveries. In example 2 we don't know this is the case. At this stage it probably does not really matter which code you use as it appears they patients are being discharged.