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https://www.d.umn.edu/medweb/Modules/OB-Long/DeliveryNote.pdf
Example of Delivery Note: Stage I: 7 hours 35 minutes Spontaneous rupture of membranes with normal progressive labor following. Fetal heart tones normal with variable decelerations over last half hour of Stage I with good return to baseline. Good accelerations throughout.
https://fpnotebook.com/OB/Ld/DlvryNt.htm
Active Management of Labor Amnioinfusion Arrest of the Second Stage of Labor Bradley Method Breech Delivery Breech Presentation Brow Presentation Cervical Ripening Compound Presentation Delivery Note Doula Emergency Department Active Labor Presentation External Cephalic Version Face Presentation Failure to Progress Fetal Malpresentation First ...
https://www.gwumc.edu/edu/obgyn/notes/delivery.html
Normal spontaneous vaginal delivery (or forceps or vacuum assisted vaginal delivery), of live male or female infact, position (i.e., LOA, ROA, ROP, etc.) over intact perineum (or if episiotomy done) with or without epidural anesthesia.
http://www.stritch.luc.edu/lumen/MedEd/obgyne/tools.pdf
1. Sample Admission to Labor and Delivery Note Date & time Identification (includes age, gravidity, parity, estimated gestational age, and reason for admission): 26yo G3P1A1 @ 38W5D EGA presents with painful contractions since noon. Pt reports good fetal movement, and denies rupture of membranes or vaginal bleeding.File Size: 134KB
http://www.jasoncartermd.com/resources/patient/files/OB%5EDictations.pdf
Sample Vacuum Note: _____ y/o now P _____ experienced vacuum/forceps assisted delivery) over 2° MLE on (date) @ (time). Due to (non reassuring heart rate/prolonged second stage/maternal exhaustion, etc.), the vacuum was placed at (+2) station, (ROA) position after bladder emptied and anesthesia found to be adequate. Infant was delivered withinFile Size: 54KB
https://med.dartmouth-hitchcock.org/obstetrics_safety/sample_delivery_note_shoulder_dystocia_.html
A fill-in-the-blank sample shoulder dystocia delivery note.
https://healthproadvice.com/profession/Healthcare-Provider-SOAP-Note
Example OB Birth or Delivery Note The patient was found to be completely dilated at 2119 and spontaneously bearing down at the peak of each contraction. After effectively pushing, the patient delivered a viable female infant over intact perineum at 2123. The anterior shoulder delivered easily, and the postpartum oxytocin bolus initiated.
http://www.stritch.luc.edu/lumen/MedEd/obgyne/Clerkship_Guide.pdf
Labor patients should have progress notes written every 4 hours in latent labor and every 2 hours in active labor. You are responsible for having notes written on your patients‐ we will not remind you. Once your note is written, please let your residents know and one will review it with you if time permits.File Size: 423KB
https://medicine.umich.edu/sites/default/files/content/downloads/Student%20survival%20guide%202013.pdf
residents who rotate with the OB team on Labor and Delivery. They generally help manage the lower-risk laboring patients. Their goals are generally to gain experience with normal vaginal deliveries and lower-risk obstetrical issues.File Size: 356KB
https://www.hopkinsmedicine.org/gynecology_obstetrics/education/medstudents/_docs/Clinical_Affiliates/Sinai-CRIB-SHEETS.pdf
A/P: _____wk IUP in latent labor Routine labs Patient desires epidural Rubella/RhoGAM if indicated Follow labor curve DELIVERY NOTE (NSVD) of FTLFC in cephalic presentation (LOA) position over ML epis. APGARS ___,____ Bulb suction on perineum, spontaneous breath & cry. (Peds present) No complications. EBL 500 cc.
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