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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______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ Estimated date of delivery_______________ Best estimated gestational age_____________ Criteria (1): ❏ Gestational age less than or equal to 31 6/7 weeks and ❏ Singleton or multiple pregnancy at risk for delivery within the next 30 minutes to 24 hours and either ❏ Active preterm labor with cervix 4–8 cm dilated or preterm premature rupt...


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: _________________________________ ...


This list of Patient Safety resources, prepared by College Resource Center librarians from other sources, is provided for information only.  Referral to these sites does not imply the endorsement of The American College of Obstetricians and Gynecologists of either the organization or their contents, expressed views, programs, or political activities.


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...


10.
November 2011

Fetal Presentation (1) ❏ Vertex ❏ Other___________ ❏ If other, physician or certified nurse–midwife notified Estimated fetal weight___________ ❏ Patient has a completed medical history and physical examination ❏ Known allergies identified____________________ ❏ Medical factors that could effect anesthetic choices identified____________________ ❏ Pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (2, 3) ❏ Other special concerns identified (eg, medical problems and special needs):_________________ ❏ Patient counseled about risks and benefits ...


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