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 availability and timeliness of services provided by the obstetric, newborn, and anesthetic caregivers ❏ After balancing the risks and chances of success, the patient and her health care provider have concluded that the patient continues to be an appropriate candidate for TOLAC ❏ Yes ❏ No ❏ Patient has signed a consent form for TOLAC and emergency cesarean delivery as required by the institution ❏ Health care provider providing prenatal care has informed the Labor and Delivery team that the patient is attempting TOLAC: ❏ Physician or certified nurse midwife ❏ Anesthesiologist ❏ Pediatrician or other appropriate health care provider ❏ Appropriate nursing staff ❏ Misoprostol (prostaglandin E1) is NOT used to ripen the cervix or induce labor when the fetus is potentially viable References 1. Vaginal birth after previous cesarean delivery. Committee Opinion 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 TRIAL OF LABOR AFTER PREVIOUS CESAREAN DELIVERY (INTRAPARTUM ADMISSION) Number 9 • November 2012 How to Use This Checklist The Patient Safety Checklist on Trial of Labor After Previous Cesarean Delivery should be completed by the health care provider when a patient who is undergoing a trial of labor after a previous cesarean delivery is admitted to Labor and Delivery. 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. Trial of labor after previous cesarean delivery (intrapartum admission). Patient Safety Checklist No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1256–7.

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