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Date______________ Patient _______________________________ Date of birth___________ MR #___________ Physician or certified nurse–midwife______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ Estimated date of delivery_______________ Best estimated gestational age_____________ Criteria (1): ❏ Gestational age less than or equal to 31 6/7 weeks and ❏ Singleton or multiple pregnancy at risk for delivery within the next 30 minutes to 24 hours and either ❏ Active preterm labor with cervix 4–8 cm dilated or preterm premature rupt...


Indication for induction: (choose one) ❏ Medical complication or condition (1): Diagnosis:_________________________________ ❏ Nonmedically indicated (1–3): Circumstances:___________________________________ Patient counseled about risks, benefits, and alternatives to induction of labor (1) ❏ Consent form signed as required by institution Bishop Score (see below) (1):_________ ❏ Pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (4, 5) ❏ Special concerns (eg, allergies, medical problems, and special needs):______________________ To be complete...


Date______________ Patient _______________________________ Date of birth___________ MR #____________ Physician _______________________________________ Gravidity/Parity__________________________________ Best estimated gestational age____________ Indication_________________ ❏ Patient has a complete medical history and physical examination ❏ Known allergies identified ❏ Medical factors that could affect anesthetic choices identified ❏ Patient counseled about risks and benefits of cesarean delivery versus trial of labor and vaginal delivery (1, 2) ❏ Consent form signed as required by inst...


Date______________ Patient ______________________________ Date of birth__________ MR #_____________ Physician or certified nurse–midwife______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ Estimated date of delivery________________ Best estimated gestational age (at admission)_______________ Proposed cesarean delivery date___________ Indication (choose one): ❏ Medically indicated: Diagnosis:_______________________________________________ ❏ Repeat cesarean delivery (choose one) (1, 2): ❏ Trial of labor not appropriate: Rea...


5.
November 2011

Fetal Presentation (1) ❏ Vertex ❏ Other___________ ❏ If other, physician or certified nurse–midwife notified Estimated fetal weight___________ ❏ Patient has a completed medical history and physical examination ❏ Known allergies identified____________________ ❏ Medical factors that could effect anesthetic choices identified____________________ ❏ Pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (2, 3) ❏ Other special concerns identified (eg, medical problems and special needs):_________________ ❏ Patient counseled about risks and benefits ...


American Congress of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998