Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with regular uterine contractions occurring [X] times per [Y] minutes, associated with [cervical change / progressive effacement / dilation]. Patient reports [presence/absence] of vaginal bleeding, fluid leakage, or pelvic pressure. Gestational age confirmed at [X] weeks by [LMP/Early Ultrasound].
Clinical Examination Findings
Abdominal exam: Uterus soft between contractions, nontender. Fetal heart rate [X] bpm, reactive. Sterile speculum exam: [No/Evidence] of ROM (nitrazine/ferning). Digital cervical exam: Effacement [X]%, Dilation [X] cm, Station [X]. Cervical length via TVUS: [X] cm.
Treatment Protocol
Initiate tocolysis with [Nifedipine/Indomethacin] for uterine quiescence. Administer antenatal corticosteroids (Betamethasone 12mg IM q24h x 2 doses) for fetal lung maturation. Consider Magnesium Sulfate for fetal neuroprotection if <32 weeks. Monitor maternal vitals and fetal heart rate continuously.