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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: _________________________________ ...


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...


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