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Delivery Note

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Delivery Note

  • Document
  • History:
  1. This __ year old G_ P___ with ED+C __/__/__
  2. delivered at __ weeks gestation
  3. a ____ gram (sex) infant
  4. with Apgars of __ and __ at 1 and 5 min
  5. at __:__ on __/__/__.
  • Document
  • Pregnancy was complicated by:
  1. Gestational Diabetes
  2. Preterm Labor
  3. Prolonged Rupture of Membranes
  4. Pregnancy Induced Hypertension
  • Document
  • Dictated from Admission Note:
  1. History of present illness
  2. Prenatal course
  3. Prenatal Labs
  4. Medications
  5. Medication Allergies
  6. Family History
  7. Past medical history
  8. Initial physical exam
  • Document
  • Stage 1 (date and time of onset, Stage duration):
  1. Monitors and tracings
    1. External Fetal Monitor or Fetal Scalp Electrode
    2. Fetal Heart Tracing variability
      1. Fetal heart accelerations (long term variability)
      2. Beat to beat variability by fetal scalp electrode
    3. Signs of Fetal Distress by Fetal Heart Tracing
      1. Variable Decelerations
      2. Late Decelerations
      3. Fetal Tachycardia
      4. Fetal Bradycardia
      5. Diminished Fetal Heart Rate variability
  2. Adequate contraction pattern by Tocometry
    1. Frequency and subjective intensity of contractions
    2. Montevideo Units by intrauterine pressure catheter
  3. Labor Induction or augmentation
    1. Cervical Ripening with Prostaglandin gels
    2. Pitocin: Maximum units/hour used
  4. Complications
  5. Labor Anesthesia
    1. Intravenous Narcotics (e.g. Nubain, Fentanyl)
    2. Intrathecal Morphine or Epidural Anesthesia
  6. Rupture of Membranes (SROM or AROM)
    1. Time and duration of Rupture of Membranes
    2. Amniotic fluid color
    3. Presence of thick particulate meconium
  • Document
  • Stage 2 (Date and time of onset, Stage duration):
  1. Monitors and tracings
  2. Labor Anesthesia
  3. Complications
    1. Nuchal cord
    2. Shoulder Dystocia
  4. Delivery type
    1. Normal Spontaneous Vaginal Delivery
    2. Vacuum Assisted Delivery
    3. Forceps Assisted Delivery
  5. Repeat History Line above noting
    1. Maternal age with Gravida and Parity
    2. Gestational age, weight, and Sex
    3. Fetal Vertex Position
    4. APGAR Score
    5. Time and date of delivery
  6. Episiotomy or Perineal Laceration
    1. Midline or mediolateral episiotomy
    2. Degree of perineal Laceration (first to fourth)
    3. Suture Used (Vicryl, Chromic, Dexon)
  7. Neonatal Resuscitation
    1. Suction at perineum and at warmer
      1. Intubation
      2. Delee suction
      3. Bulb suction
    2. Oxygen
    3. Positive Pressure Ventilations
    4. Chest Compressions
    5. Resuscitation medications
      1. Naloxone
      2. Epinephrine
      3. Glucose
      4. Intravenous FluidResuscitation
  • Document
  • Stage 3 (Date and time of onset, Stage duration)
  1. Placenta delivered intact with 3 vessel cord
  2. Pitocin amount given IM or Infused
  • Document
  • Summary
  1. Total Labor Time:
  2. Estimated Blood Loss (300 cc is common)
  3. Attending at delivery:
  4. Condition of Mother and baby after delivery