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 perform an emergency cesarean delivery and the availability and timeliness of services provided by the obstetric, newborn, and anesthetic caregivers (1) ❏ Documentation of previous cesarean delivery available ❏ Yes: Indication:____________________________________________________________________ ❏ Previous cesarean incision is neither a classical incision nor a T-incision and there is no history of uterine rupture or extensive transfundal uterine surgery ❏ No ❏ Vaginal delivery is otherwise not contraindicated for TOLAC ❏ After balancing the risks and chances of success, the patient and her health care provider feel that the patient is an appropriate candidate (2) ❏ Yes ❏ No References 1. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. ^ 2. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63. [PubMed] [Obstetrics & Gynecology] ^ Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The American College of Obstetricians and Gynecologists has developed a series of Patient Safety Checklists to help facilitate the standardization process. This checklist reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular checklist may be adapted to local resources, standardization of checklists within an institution is strongly encouraged. ✓ Patient Safety Checklist APPROPRIATENESS OF TRIAL OF LABOR AFTER PREVIOUS CESAREAN DELIVERY (ANTEPARTUM PERIOD) Number 8 • November 2012 How to Use This Checklist The Patient Safety Checklist on Appropriateness of Trial of Labor After Previous Cesarean Delivery should be completed by the health care provider early in the course of prenatal care for patients for whom a trial of labor after a previous cesarean delivery may be appropriate. Copyright November 2012 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. Appropriateness of trial of labor after previous cesarean delivery (antepartum period). Patient Safety Checklist No. 8. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1254–5.

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