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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://www.stepwards.com/?page_id=3982
Labor Progress Note Labor and delivery update: TIME Subjective: pain/pressure characterization Objective: Vitals Fetal Heart Rate Baseline rate: Variability: absent, minimal 1-5 bpm, moderate 6-25 bpm, severe >25 bpm Accelerations: present/absent Decelerations: present/absent Tochograph q#min SVE (per MD/PA) Assessment and Plan: AGE yo G##P#### @ #weeks # days in active labor.
https://images.template.net/wp-content/uploads/2015/12/17104553/Labour-and-delivery-Soap-Note-Word-Free-Download.doc
Anticipate vaginal delivery. Change in activity. Sample Delivery Note. This is a . 19. year old . G2 now P2 . who was admitted for . active labor / post-term induction / preeclampsia etc. She progressed . spontaneously / with pitocin augmentation . to the second stage of labor. She pushed for ___hours/min. She delivered a . viable / nonviable ...
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. Comment if meconium (and if so, Delee suction at perineum) or nuchal cord.
http://www.jasoncartermd.com/resources/patient/files/OB%5EDictations.pdf
Sample Delivery Note _____ y/o now P _____ experienced (NSVD, VBAC, vacuum/forceps assisted delivery) over (intact perineum, 1° MLE, 2° MLE, etc) on (date) @ (time). The infant's head was delivered in a controlled manner. The OP and nares were then (bulb, DeLee) suctioned on the perineum. Amniotic fluid was (clear, mec stained). No nuchalFile Size: 54KB
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
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