Obstetric SOAP Notes Example: Arrest of Dilation (With Free Template + Case Study)
Introduction
If you want OB documentation that’s accurate, defensible, and fast, SOAP notes are your best tool. This case walks through arrest of dilatation, from admission to delivery, using Subjective, Objective, Assessment, and Plan — exactly how you’d chart in practice.
👉 Grab the FREE OB SOAP Note Template + Case Study Pack. Print-ready forms save time for writing and teaching SOAP notes.
Why SOAP Notes Matter in OB
I used to teach these clinical steps to midwives. Now, as an autistic nurse leader, I teach how to use these tools to improve their work-life balance. If you’re here because you’re exhausted, read my Burnout Recovery Plan.
Why use SOAP notes?
- Show your clinical reasoning clearly
- Protect you legally and clinically
- Document patient-centered care
In OB, especially arrest of dilatation, your notes should show:
- Assessment findings
- Options you offered
- Patient decisions and informed consent
- How did you monitor labor progress
Clear notes are essential because labor can change fast.
For more examples and guidance, see general SOAP Notes for Nurses.
Case Overview: Arrest of Dilation
Scenario: 30-year-old G2P1 at 39w4d in early labor, history of precipitous labor, wants an unmedicated water birth. Progress stalls.
Admission SOAP Note (2/19/2025 2230)
S (Subjective):
30 y.o. G2P1 at 39 4/7 wks reports contractions q5 min x 2 hrs; states last labor progressed quickly and desires an unmedicated water birth. Partners/support persons present.
O (Objective):
- Vitals: BP 110/70, P64, afebrile
- SVE: 4cm/60%/-2
- FHT: 145s, moderate variability, +accels, no decels
- UA: Neg proteinuria, neg glucose
- GBS: Negative
- Labs: ABO A+, antibody screen neg
A (Assessment):
IUP at 39 4/7 wks, early labor, Category I FHTs, intact membranes.
P (Plan):
- Admit for labor support
- Options discussed: discharge vs continued observation
- Patient opts for admission
- Labs: T&S, H/H ordered
- Pain management: warm water immersion
👉 This admission note layout is in the free template — download it now and adapt it.
Progress SOAP Notes (Significant Time Points)
Improving perinatal collaboration across health care disciplines is key.
Progress Note #1 (2/19/2025 2330)
S: Reports increasing pressure/pain 8/10, requests vaginal exam for tub admission
O: VSS; SVE 5cm/80%/-1; FHT reassuring; contractions moderate
A: Active labor
P: Proceed with warm water immersion
Progress Note #2 (0200)
S: Urge to push noted on birth ball
O: VSS; SVE 7cm/100%/-1; moderate contractions
A: Active labor continues
P: Patient to exit tub per hospital protocol
Progress Note #3 (0700)
S: Pt reports labor slowing
O: SVE unchanged at 7cm/100%/-1; contractions q6-15 mins
A: Arrest of dilatation, Category I FHTs
P:
- Options discussed: nipple stimulation, Pitocin, AROM
- Pt declines augmentation
- Expectant management continues
- The collaborating physician consulted
Evidence-Based Resources: From Obstetric SOAP Notes to Nontraditional Career Guides
I’ve spent years gathering resources to make our clinical lives easier and our recovery more intentional. You can find my full toolkit below.
1. 15 Remote and Nontraditional Jobs for Nurses
Explore career paths that utilize your clinical expertise in new environments. [Download the Career Guide]
2. 30-Day Nurse Burnout Recovery Plan
A structured, physiological approach to nervous system regulation and professional restoration. [Access the Recovery Plan]
3. Obstetric SOAP Notes Template
Streamline your clinical documentation with this midwife-approved template for arrest of dilation and complex cases. [Get the SOAP Template]
Attending OB SOAP Note
S: Evaluated for arrest of dilatation after 5+ hours at 7cm
O: Confirmed Category I tracings, stable vitals
A: Active labor with arrest of dilatation
P: Recommended AROM, Pitocin augmentation; risks/benefits discussed; patient declines Pitocin
Delivery / Birth Note (SOAP-style Summary)
S: Pt reports exhaustion but continued desire for an unmedicated birth
O: Complete dilation achieved after AROM; SVD, baby vigorous, Apgars 9/9
A: Successful spontaneous vaginal birth
P:
- Routine postpartum care
- Initiated skin-to-skin & breastfeeding
Key Tips for OB SOAP Notes (Updated & Accurate)
1. Arrest of Dilatation: What It Is
Active phase arrest is defined as no cervical change for ≥6 hours with adequate contractions, or ≥4 hours with inadequate contractions once ≥6cm (The 2025 ACOG and CMQCC guidelines). This is exactly how you’d document it in SOAP notes for defensible, evidence-based care.
2. Patient Autonomy & Respectful Maternity Care
Documentation should include:
- Options offered and discussed
- Risks and benefits
- Patient preferences and informed consent
- How the patient was supported according to AWHONN’s respectful maternity care principles
3. SOAP Notes
The SOAP (or SOAPIE) documentation style clearly and succinctly captures assessment, patient preferences, plan, and interventions.
Want the Templates? Grab the Free Download
I made printable OB SOAP note templates + this full case study available for nurses just like you.
👉 Get the FREE SOAP Note Template + Case Study Pack
You can also use them with other scenarios — postpartum complications, triage assessments, lactation issues, etc.
Where This Fits in Your Practice
If you’re new to SOAP notes or want deeper guidance on crafting strong clinical documentation, check out my full guide:
👉 SOAP Notes for Nurses — with examples and how-tos
This case study pairs perfectly with that guide — one shows how to document, the other gives you an example + downloadable forms.
Final Thought
SOAP notes are powerful because they make your clinical judgment visible to colleagues, auditors, and your future self. They shouldn’t be a chore; they should be a tool. Use the free templates, spend a little time upfront structuring them well, and you’ll save time and protect your practice.
