Vaginal Delivery Procedure Note

(Omit sections that are not applicable; do not include "N/A" placeholders. Use "pending" for values expected but not yet available. Include calendar date with all times to preserve context. Do not infer values such as Apgar scores, birthweight, cord gas results, laceration degree, QBL/EBL, or diagnosis of shoulder dystocia without explicit documentation.)

Date/Time of Delivery: [Date and exact time of birth]    Date/Time of Note: [Date and time note authored]

Location: [Facility and unit/room]    Delivering Clinician: [Name, credentials]    Assistants/Team: [Names/roles]    Anesthesia Provider: [Name/role] (Omit if no anesthesia provider involved)

G/P: [Gravida/Para]    Gestational Age: [Weeks+days]    Presentation: [cephalic / breech / other]    Pertinent Diagnoses: [Pertinent maternal/fetal diagnoses relevant to delivery] (Concise list only; omit if none)

Indication and Labor Course

[Brief narrative summarizing: reason for admission and indication for delivery (spontaneous labor / induction with indication / PROM / maternal or fetal indication); rupture of membranes details (date/time, SROM/AROM, fluid character, meconium if present); analgesia/anesthesia method; second stage details if clinically relevant (duration, fetal position/rotation, indication for operative delivery if applicable); intrapartum complications affecting delivery and treatments given] (Keep to 2–4 sentences; this is a summary, not a full labor progress note. Include TOLAC/VBAC context only if applicable.)

Consent

(Include this section only if operative vaginal delivery, episiotomy, or significant repair was performed.)

Informed consent for [vacuum-assisted delivery / forceps-assisted delivery / episiotomy / laceration repair] was obtained from the patient [and support person if present]. [Risks, benefits, alternatives, and indications were discussed / Emergent circumstances were explained with limited time for discussion.] Patient agreed to proceed. (Specify procedures discussed. If emergent, document the emergent nature and what was communicated.)

Delivery

[Delivery type: spontaneous vaginal delivery / vacuum-assisted vaginal delivery / forceps-assisted vaginal delivery] at [exact date and time of birth]. Fetal head position at delivery: [OA / OP / OT / unknown]. Nuchal cord: [absent / present and reduced / present and delivered through]. Episiotomy: [none / midline / mediolateral]. [Shoulders and body delivered without difficulty / Brief description of any difficulty]. (Include VBAC statement if applicable: "Successful VBAC; no uterine rupture.")

Operative Vaginal Details

(Include this subsection only if vacuum or forceps were used.)

• Indication: [Non-reassuring fetal status / maternal exhaustion / prolonged second stage / other]
• Station and Position at Application: [Station] / [Position]
• Fetal Status at Application: [Category I / II / III; baseline FHR]
• Vacuum Delivery (if applicable):
  • Device Type: [Device name]
  • Pressure Setting: [Value in mmHg]
  • Number of Pulls: [Number]
  • Pop-offs: [Number]
  • Application-to-Delivery Time: [Minutes]
• Forceps Delivery (if applicable):
  • Forceps Type: [Type]
  • Position Confirmed After Placement: [yes / no]
  • Number of Pulls: [Number]
  • Effort Required: [Brief qualitative description]
• Procedure Course: [Uncomplicated / difficulties encountered / procedure abandoned and reason]

Shoulder Dystocia

(Include this subsection only if shoulder dystocia occurred.)

• Time Head Delivered: [Date and time]
• Time Body Delivered: [Date and time]
• Head-to-Body Interval: [Duration in seconds]
• Maneuvers Performed (in sequence): [List maneuvers in order performed: McRoberts, suprapubic pressure, delivery of posterior arm, Woods screw, Rubin, Gaskin, other]
• Fundal Pressure: [avoided / applied] (Document explicitly; fundal pressure should be avoided.)
• Personnel Called: [Teams/personnel mobilized and arrival times if available]
• Immediate Concerns: [Neonatal assessment findings; maternal concerns]

Newborn

(Duplicate the following block for each infant; label Infant A, B, etc. for multiples.)

Infant [A]

• Time of Birth: [Date and exact time]
• Sex: [female / male / indeterminate]
• Birthweight: [Grams] (Use "pending" if not yet available.)
• Apgar Scores: 1 min: [Score] ([resuscitation interventions at this time, if any]); 5 min: [Score] ([interventions]); 10 min: [Score] (Include 10-minute score only if obtained.)
• Cord Management: Delayed clamping: [yes / no], [approximate duration if documented]; Cord gases: [obtained / not obtained], [results or "pending"]
• Disposition: [Skin-to-skin with birthing parent / routine nursery / NICU evaluation/transfer]
• Immediate Findings: [Notable findings on initial assessment] (Include clavicle assessment, upper extremity movement, bruising, or cephalohematoma if applicable after shoulder dystocia or operative delivery.)

Placenta and Cord

• Placental Delivery: [spontaneous / controlled cord traction / manual extraction] at [date and time]
• Placenta and Membranes: [Intact and complete / describe abnormalities or missing cotyledon concern]
• Cord Vessels: [Three-vessel / two-vessel / not assessed]
• Uterine Exploration: [Not performed / performed for indication with findings] (Include only if performed.)
• Pathology Disposition: [Sent to pathology with indication / routine discard or hold per policy]

Perineum and Repair

Cervix, vagina, and perineum were examined. Lacerations: [none identified / present as detailed below].

• Perineal Laceration: [none / 1st degree / 2nd degree / 3rd degree (3a/3b/3c) / 4th degree]
• Other Lacerations: [vaginal sulcus / labial / periurethral / cervical / none]
• Episiotomy: [none / midline / mediolateral]
• Anesthesia for Repair: [Existing neuraxial / local infiltration with agent and volume / none required]
• Repair Details: [Suture material(s), technique, and layers repaired; hemostasis confirmed]

(For OASIS—3rd or 4th degree lacerations—add the following:)

• OASIS Documentation: Rectal exam performed before and after repair. [IAS / EAS involvement described]. No suture transfixes rectal mucosa. Plan: [antibiotic regimen] and stool softener initiated.

Blood Loss and Uterine Tone

• Blood Loss: [Quantitative Blood Loss in mL] (Use QBL; use EBL only if QBL unavailable. Use "pending" if calculation in progress.)
• Uterine Tone: [Firm / boggy with response to massage]
• Uterotonics: [Oxytocin per routine protocol / additional agents with doses]

(If postpartum hemorrhage occurred, include the following:)

• Hemorrhage Management: Suspected etiology: [atony / trauma / retained tissue / coagulopathy]. Interventions (in sequence): [uterine massage, uterotonics with agents/doses, TXA, tamponade, procedural interventions, transfusion products]. Labs obtained: [CBC, coags, type and screen]. Hemorrhage protocol: [activated / not activated]. Patient response: [Describe response to interventions].

Complications

(Include this section only if complications occurred. Use problem-oriented format.)

• [Complication]: [Description of event] — [Actions taken] — [Outcome/status]

Maternal Condition and Plan

• Postpartum Status: [Hemodynamically stable/unstable]; fundus [firm/boggy at level]; lochia [moderate/other]; pain [controlled/uncontrolled]; voiding [spontaneous / catheterized]
• Disposition: [Postpartum unit / higher level of care with reason]
• Orders: [Monitoring frequency if non-routine; uterotonics; antibiotics; analgesics; VTE prophylaxis if indicated]
• Labs/Follow-up: [Labs ordered with action thresholds; Rh immune globulin if indicated; specialty referrals or follow-up triggered by complications]

Newborn Plan

• Handoff: [Receiving care team and current location]
• Feeding Plan: [Breastfeeding / formula / donor milk / to be determined]
• Monitoring: [Glucose monitoring if indicated; other monitoring]
• Pending Evaluations: [Screenings, labs, consults, or concerns to follow]

Communication

(Include this section for adverse events: operative delivery, shoulder dystocia, hemorrhage, OASIS, or NICU transfer.)

Events were discussed with the patient [and support person]. Counseling provided regarding [clinical course, expected recovery, warning signs, and implications for future pregnancies as applicable]. (Keep factual; avoid speculative statements.)