Date______________ Patient _______________________________ Date of birth____________ MR #___________
Physician or certified nurse–midwife______________________________ Last menstrual period__________________
Estimated date of delivery_______________ Best estimated gestational age_____________
❏ Patient counseled on the risks, benefits, chances of success, and alternatives of trial of labor after previous
cesarean delivery (TOLAC) (1)
❏ Patient is provided with information about TOLAC
❏ Patient is informed of her hospital’s ability to perfor...