Delivery Note
Dilation onset: patient became fully dilated at __ am/pm (exact time).
Time spent pushing: patient pushed for __ (min/hrs)
Nature of delivery: spontaneous/vacuum assisted/forceps assisted delivery of a (sex) liveborn baby at __ am/pm over an intact/midline episiotomy/2nd degree lacerations perineum from ROA/LOA/OP/LOT position.
Characteristics of newborn:
- Apgar score: 1 min score (), 5 min score ()
- Weight: ___
Pediatricians preset? Yes/no
Delivery of placenta: placenta was delivered spontaneously/with gentle traction/manually. Intact with 1/2/3 vessel cord.
Episiotomy performed? no/1/2/3 epiostomy performed. Repaired with 2-0, 3-0 vicryl/chromic
Cervix/vagina exam:
- No lacerations
- Fundus firm
- Excellent hemostasis
Rectum exam: no stitch, mucosa intact
Obstetricians:
Anesthesia: epidural/IV sedation/ lidocaine
Estimated blood loss (EBL):
- Normal: 400 mL NSVD; hemorrhage > 500 mL
- Normal: 800 mL LTCS; hemorrhage > 1000 mL
Maternal blood type:
Rubella status:
Mr. Stepwards, MS3
DATE
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