Version June 2024
| 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: ____________________________________________________________ |
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