Operative Vaginal Delivery Procedure Note (Vacuum/Forceps)

Patient: [Patient name and identifiers]

Date/Time of Delivery: [Date and time infant was born]

Location: [L&D room / OR / other]

Primary Operator: [Name, role]

Assistants: [Names and roles of assistants present]

Anesthesia: [Type and provider name / none]

Neonatal Team: [Present at delivery / notified and arrived / notified and unavailable / not present / unknown]

Procedure Summary

Procedure performed: [Vacuum-assisted vaginal delivery / forceps-assisted vaginal delivery / sequential instruments / attempted OVD converted to cesarean]

Primary indication: [Nonreassuring fetal status / prolonged second stage / arrest of descent / maternal exhaustion / shorten second stage for maternal condition / other]

[Clinical context: duration of second stage, fetal heart rate category and concerning features at time of decision, relevant maternal factors] (1–2 sentences; keep concise and factual.)

Informed Consent

Consent type: [Written / verbal / emergency exception with rationale / not documented with explanation]

[Statement confirming discussion of risks (potential cesarean, maternal lacerations, hemorrhage, neonatal scalp trauma and bleeding complications), benefits, and alternatives (continued pushing, cesarean delivery), and that patient agreed to proceed.] (If consent not obtained or documented, state "Not documented" with explanation.)

Prerequisites Confirmed

(Select "Confirmed" only if explicitly verified; do not infer.)

• Cervix fully dilated: [Confirmed / not confirmed / unknown]
• Membranes ruptured: [Confirmed / not confirmed / unknown]
• Fetal head engaged at appropriate station: [Confirmed / not confirmed / unknown]
• Fetal head position assessed: [Confirmed / not confirmed / unknown]
• Pelvis assessed as adequate: [Confirmed / not confirmed / unknown]
• Adequate analgesia/anesthesia in place: [Confirmed / not confirmed / unknown]
• Bladder emptied: [Confirmed / not confirmed / unknown]
• Operator privileged for procedure: [Confirmed / not confirmed / unknown]
• Backup plan for cesarean available: [Confirmed / not confirmed / unknown]
• Contraindications: [None identified / proceeding despite relative contraindication with rationale / unknown]
• Pre-procedure verification/time-out: [Performed / not performed / unknown]

Pre-Application Assessment

(Document explicitly; do not infer. If not assessed, enter "Unknown" with brief explanation.)

• Station at application: [Station with reference system; indicate whether caput excluded] (e.g., "+2 by ACOG system, caput excluded")
• Position at application: [OA / LOA / ROA / OP / ROP / LOP / LOT / ROT / other / unknown]
• Assessment method: [Clinical exam only / ultrasound confirmed position / unknown]

Procedure Details

(Include only the instrument-specific subsection(s) that apply.)

Vacuum-Assisted Delivery

• Cup type and size: [Rigid / soft / posterior; size if known / unknown]
• Placement: [At flexion point confirmed / not at flexion point / unknown]; Maternal tissue trapped: [No / yes / unknown]
• Vacuum pressure: Target [mmHg]; Maximum achieved [mmHg]
• Total application duration: [Duration / unknown]
• Traction efforts (pulls): [Number / unknown]
• Descent with pulls: [Yes / no / mixed / unknown]
• Cup detachments (pop-offs): [Number and circumstances / none / unknown]
• Pre-agreed stopping criteria: [Criteria]; Criteria met: [Yes / no / unknown]
• Delivery of head: [Vacuum in place / vacuum removed prior / unknown]

Forceps-Assisted Delivery

• Forceps type: [Simpson / Tucker-McLane / Kielland / other]
• Classification: [Outlet / low / mid]
• Rotational: [Non-rotational / rotational]
• Number of applications: [Number / unknown]
• Position after blade placement: [Sagittal suture midline confirmed / not confirmed / unknown]
• Traction efforts: [Number / unknown]; Descent observed: [Yes / no / mixed / unknown]
• Rotation performed: [Method and degree / none / unknown]
• Episiotomy: [No / yes with type and rationale / unknown]
• Pre-agreed stopping criteria: [Criteria]; Criteria met: [Yes / no / unknown]

Sequential Instruments or Failed OVD

• Rationale for changing approach: [Rationale]
• Additional consultation obtained: [Yes with name / no / unknown]
• Updated counseling: [Yes / no / not applicable / unknown]
• Instrument metrics: (Document separately in relevant subsections above.)
• Final outcome: [Vaginal delivery after second instrument / converted to cesarean with reference to operative note]

[Procedural narrative: key steps, traction with contractions, descent and rotation achieved, decision points, outcome] (2–4 sentences; keep factual and concise.)

Delivery Outcome

• Infant: [Liveborn / stillborn]
• Sex: [Female / male / undetermined]
• Birthweight: [Grams / pending]
• Apgar scores: 1 min [Value]; 5 min [Value]; 10 min [Value if obtained] (Use "Pending" if not yet available.)
• Cord gases: [Obtained / not obtained]; Arterial pH [Value]; Venous pH [Value] (Use "Pending" if not yet resulted.)

Maternal Findings

• Estimated blood loss: [mL]
• Perineal laceration: [None / 1st degree / 2nd degree / 3rd degree / 4th degree]
• Other lacerations: [None / cervical / vaginal sulcus / labial / periurethral / other with details]
• Repair: [Description with materials / documented in separate note / not applicable]
• Complications: [None / hemorrhage requiring intervention / hematoma / shoulder dystocia with maneuvers / other with details]
• Maternal condition: [Stable / concerns]; Disposition: [Recovery / L&D observation / OR / ICU]

Neonatal Findings

• Status at delivery: [Tone, respirations, response]
• Instrument-related findings: [No injuries noted / scalp laceration / scalp abrasion / cephalohematoma / concern for subgaleal hemorrhage / facial bruising / facial nerve palsy / other with details]
• Disposition: [Routine care / NICU / other]; OVD-related monitoring: [Description / none]

Post-Procedure Plan

• Prophylactic antibiotics: [Given with drug, dose, timing / not given with reason / not applicable]
• Maternal orders related to OVD: [Monitoring, perineal care, analgesia, bladder management]
• Neonatal orders related to OVD: [Monitoring for scalp swelling, neuro checks / none]

(Safety-critical: Station, position, and device metrics must be explicitly documented; do not infer. Enter "Unknown" if not available in dictation rather than omitting. Use "Pending" for expected values not yet available. Include only relevant device subsections.)

Operator Signature: [Name, credentials, date/time]