Components of a Vaginal Delivery Procedure Note
A comprehensive vaginal delivery procedure note should include detailed documentation of the labor course, delivery process, and immediate postpartum period to ensure optimal maternal and neonatal outcomes. 1
Patient Information and Pre-Delivery Assessment
- Maternal demographics and obstetric history
- Gestational age and pregnancy complications
- Pre-delivery vital signs
- Cervical examination findings (dilatation, effacement, station, position)
- Bishop score assessment (station of presenting part, cervical dilatation, effacement, consistency, and position) 1
- Fetal presentation and position
- Fetal heart rate pattern and category before delivery
Labor Management
- Timing of labor (spontaneous onset vs. induced)
- If induced: method of induction (oxytocin, artificial rupture of membranes, mechanical methods) 1, 2
- Oxytocin administration details if used (starting dose, incremental increases, maximum dose) 2
- Duration of first and second stages of labor
- Analgesia/anesthesia used (type, timing, effectiveness) 1
- Maternal position during labor and delivery
- Hemodynamic monitoring details (blood pressure, heart rate, oxygen saturation) 1
Delivery Process
- Date and time of delivery
- Personnel present (obstetrician, midwife, anesthesiologist, pediatrician)
- Maternal position during delivery
- Episiotomy details if performed (type, indication)
- Operative assistance if used:
- Manual rotation if performed 5
- Delivery of head (time, nuchal cord if present)
- Delivery of shoulders and body
- Cord clamping (timing, delayed or immediate)
- Placental delivery:
- Method (spontaneous, controlled cord traction, manual removal)
- Time of delivery
- Placental inspection (complete/incomplete, abnormalities)
- Estimated blood loss 1
Immediate Postpartum Management
- Uterotonic medications administered (type, dose, route, timing) 1, 2
- Repair of lacerations or episiotomy (location, degree, suture material, technique)
- Uterine tone assessment
- Inspection of cervix, vagina, and perineum
- Postpartum hemorrhage management if applicable
- Maternal vital signs post-delivery
Neonatal Assessment
- APGAR scores at 1 and 5 minutes
- Sex of infant
- Birth weight
- Neonatal condition at birth
- Resuscitation measures if required
- Cord blood gases if collected 1
Additional Documentation
- Complications during delivery and their management
- Estimated total blood loss
- Specimens collected (placental pathology, cord blood)
- Disposition of mother and infant
Special Considerations
- For high-risk deliveries: document multidisciplinary team involvement 1
- For operative vaginal deliveries: document specific indication, station, position, and number of attempts 6, 5
- For deliveries with regional anesthesia: document type, effectiveness, and any top-ups required 1
A well-documented vaginal delivery procedure note is essential for clinical care, quality improvement, and medicolegal purposes. The note should be completed promptly after delivery while details are fresh in the clinician's mind, with particular attention to timing of events and management of any complications.