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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_____________ ❏ Patient has been counseled on the risks, benefits, chances of success, and alternatives of planned trial of labor after cesarean delivery (TOLAC) (1) ❏ Patient is informed of the facility’s ability to perform an emergency cesarean delivery and the avai...


Date______________ Patient _______________________________ Date of birth____________ MR #___________ Physician or certified nurse–midwife______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ 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...


Date______________ Patient ______________________________ Date of birth __________ MR #_____________ Physician or certified nurse–midwife______________________________ Gravidity/Parity______________________ Timing: Onset of active labor___________ Start of second stage_______ Delivery of head___________ Time shoulder dystocia recognized and help called__________ Delivery of posterior shoulder___________ Delivery of infant_________ Antepartum documentation: ❏ Assessment of pelvis ❏ History of prior cesarean delivery: Indication for cesarean delivery: _________________________________ ...


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