Operative vaginal birth procedural form (check all that apply) |
Are any contraindications present? |
No |
Yes: Fetal osteogenesis imperfecta Thrombocytopenia Hemophilia Other ____________________ |
Indication for operative vaginal birth: |
Suspicion of potential or immediate fetal compromise |
Prolonged second stage |
Maternal exhaustion |
Shortening of the second stage of labor for maternal benefit |
Breech after-coming fetal head |
Other |
Gestational age (weeks and days): ____________________ |
Fetal heart rate pattern: |
Category 1 |
Category 2 |
Category 3 |
Patient consent for operative vaginal birth was: Verbal Written |
Patient has agreed to undergo operative vaginal birth after being informed of: |
Alternatives (continued pushing, cesarean delivery) |
Fetal risks: |
For vacuum-assisted birth: Laceration; cephalohematoma; subgaleal, intracranial hemorrhage or retinal hemorrhage; brachial plexus injury |
For forceps-assisted birth: Facial lacerations, facial nerve palsy, skull fracture, intracranial hemorrhage, brachial plexus injury |
Maternal risks: Perineal lacerations, 3rd and 4th degree lacerations, vaginal sulcal tears or lacerations, need for episiotomy or emergency cesarean birth |
Benefits: Avoid cesarean birth, expedite birth, long-term fetal outcomes are the same as for 2nd stage cesarean birth |
Preprocedure assessment and procedures: |
Cervix is fully dilated and retracted |
Membranes are ruptured |
Fetal head is engaged (fetal skull is at or below 0 station) |
Position of the fetal head: |
Circle one: OA, LOA, ROA, LOT, ROT, LOP, ROP, OP, after-coming head is flexed on breech presentation |
Asynclitism: Anterior Posterior None |
Caput: None Minimal Significant |
Molding: None Present |
Ultrasound confirmation of position performed: Yes No |
Estimated fetal weight: ____________________ grams or ____________________ pounds |
Pelvis is thought to be adequate for vaginal birth |
Adequate anesthesia present (check one: Epidural Pudendal Spinal Vacuum-assisted with no anesthesia Other ____________________) |
Maternal bladder has been emptied |
Procedure: |
Location: Labor room Operating room |
Station at time of application: +5 +4 +3 +2 +1 0 |
(Outlet forceps/vacuum = fetal-presenting part at perineum; low forceps/vacuum = fetal-presenting part +2 or lower but not at perineum; midforceps/vacuum = head engaged with fetal-presenting part between 0 and +2) |
Forceps procedure: |
Type: Simpson-Luikart Tucker-McLane Simpson Kielland Piper Baby Elliot Baby Simpson Other ____________________ |
Number of pulls: 1 2 3 Other ____________________ |
Rotation of head: None 0 to 45 degrees 45 to 90 degrees >90 degrees |
Traction: Easy Moderate Strong |
Maternal effort: None Minimal Moderate Strong |
Total time instrument applied to fetal head (minutes and seconds): ____________________ |
Successful extraction? Yes No (explain: ____________________) |
Vacuum procedure: |
Gestational age is ≥34 + 0 weeks |
Type: MityOne MitySoft (bell) MityOne M-Style (mushroom) Kiwi Other ____________________ |
Maximum pressure: ____________________ |
Number of pulls: 0 1 2 3 Other ____________________ |
Number of pop-offs: ____________________ |
Rotation of head: None 0 to 45 degrees 45 to 90 degrees >90 degrees |
Traction: Easy Moderate Strong |
Maternal effort: None Minimal Moderate Strong |
Total time instrument applied to fetal head (minutes): ____________________ |
Successful extraction? Yes No (explain: ____________________) |
Newborn status: |
Sex: Male Female |
Birth weight: ____________________ grams or ____________________ pounds |
Shoulder dystocia: No Not applicable Yes (minutes: ____________________; maneuvers used to deliver: ____________________) |
Pediatric service present: Yes No |
Apgar: 1 minute: ____________________; 5 minutes: ____________________ (If <7 at 5 minutes, document additional Apgar scores at 10 minutes or more: ____________________) |
Arterial and venous cord blood gases, if obtained (should be obtained if 5-minute Apgar <5): ____________________ |
Newborn examination: Normal Abnormal (describe abnormalities, including injuries [eg, scalp laceration, scalp hematoma]: ____________________________________________________________) |
Maternal status: |
Episiotomy: No Yes: Mediolateral Midline |
Lacerations: No Yes: 1st 2nd 3rd 4th Periurethral Vaginal |
Antibiotic given if 3rd or 4th degree: No Yes (describe: ____________________________________________________________) |
Estimated blood loss: ____________________ mL |
Postpartum hemorrhage? No Yes (describe: ____________________________________________________________) |
Complications and other issues: ________________________________________________________________________________________________________________________ |
Clinician completing form: ____________________________________________________________ |
Date: ____________________________________________________________ |
Do you want to add Medilib to your home screen?