CD Document JSON Generator

Obstetrics Procedure Note

Add Section

Update Section Sorting

Update Element Sorting

CERVICAL CERCLAGE

Add Element Expand

Gestation - Cervical Cerclage (weeks)

Edit

Indication - Cervical Cerclage

Edit

Pre-Op Preparation

Edit

Vaginal Examination

Edit

Position Of Cervix

Edit

Comments

Edit

Length Of Cervix (Cm)

Edit

Uterus

Edit

Other Findings

Edit

Operative Procedure

Edit

Method Of Cerclage

Edit

Anaesthesia

Edit

Suture For Cerclage

Edit

Needle

Edit

Site Of Knot

Edit

Date And Time Operation Started

Edit

Date And Time Operation End

Edit

Post Operative Orders

Edit

Intra Operative Complications

Edit

Comments

Edit

TYPE OF PROCEDURE

Add Element Expand

CYTOLOGICAL SMEAR

Add Element Expand

Screening Summary

Edit

Cytological Smear

Edit

Specimen Type

Edit

Sampling Site

Edit

Screening Type

Edit

Screening Location

Edit

Previous Result

Edit

Clinical Summary

Edit

Hormonal Status

Edit

LMP

Edit

Type Of Contraceptive Used

Edit

Treatment History

Edit

Symptoms

Edit

Cervix

Edit

Comments

Edit

EXTERNAL CEPHALIC VERSION (ECV) PROCEDURES

Add Element Expand

Indication

Edit

Method

Edit

Number Of Attempt

Edit

Tocolysis

Edit

Ultrasound Guidance

Edit

Complications

Edit

Successful

Edit

Comments

Edit

INSERTION OF VAGINAL PESSARY

Add Element Expand

Vaginal Findings

Edit

Urethra

Edit

Vagina

Edit

Uterus

Edit

Insertion Of Vaginal Pessary

Edit

Indications - Vaginal Pessary

Edit

Types Of Pessary

Edit

Size Of Pessary (Mm)

Edit

Removal Of Pessary

Edit

Other Findings

Edit

Comments

Edit

REMOVAL OF IUD

Add Element Expand

Type Of IUD

Edit

Duration Of IUD Used

Edit

IUD Thread Present In Vagina

Edit

Comments

Edit

Complications IUD Removal

Edit

Comments Removal Of IUD

Edit

TERMINATION OF PREGNANCY (TOP)

Add Element Expand

Termination Of Pregnancy

Edit

Gestation - TOP (week)

Edit

Indications - Top

Edit

Comments

Edit

Vaginal Examination

Edit

Vulva

Edit

Vagina

Edit

Comments

Edit

Position Of Cervix

Edit

Comments

Edit

Length Of Cervix (Cm)

Edit

Dilatation Of Cervical Os (Cm)

Edit

Uterus

Edit

Method Of Top

Edit

Method Of Top

Edit

Comments

Edit

Anaesthesia - Top

Edit

Anaesthesia - Top

Edit

Comments

Edit

Complications -Top

Edit

Complications -Top

Edit

Comments

Edit

Other Findings

Edit

Comments On Top

Edit

INSTRUMENTAL DELIVERY

Add Element Expand

Date And Time Started

Edit

Date And Time Ended

Edit

Duration

Edit

Indication

Edit

Consent

Edit

Consultation With Specialist

Edit

Date And Time

Edit

Specialist

Edit

Pre Requisites

Edit

Fully Dilated Os

Edit

Position of Fetal Head

Edit

Ruptured Membrane

Edit

Cpd Excluded

Edit

Catheterization

Edit

Head Palpable Per Abdomen

Edit

Station Of The Fetal Head

Edit

Caput

Edit

Moulding

Edit

Fetal Heart Rate

Edit

Estimated Birth Weight

Edit

FORCEPS DELIVERY

Add Element Expand

Forceps Delivery

Edit

Type Of Forceps

Edit

Procedure

Edit

Patient In Lithotomy Position

Edit

Aseptic Technique Applied

Edit

Analgesia

Edit

Vaginal Examination Done

Edit

Failure To Apply

Edit

Failure To Lock

Edit

Failure To Descend

Edit

Number Of Attempt

Edit

Descent Of The Head With Traction

Edit

Episiotomy Performed

Edit

Difficulty In The Delivery Of The Shoulder And Trunk

Edit

Obstetric Trauma/Tear

Edit

Forcep Delivery

Edit

Remarks

Edit

VACUUM DELIVERY

Add Element Expand

Vacuum Delivery

Edit

Type Of Vacuum

Edit

Cup Size

Edit

Procedure

Edit

Patient In Lithotomy Position

Edit

Aseptic Technique Applied

Edit

Analgesia

Edit

Vaginal Examination Done

Edit

Episiotomy

Edit

Pressure

Edit

Pressure (Kpa/Mm/Hg)

Edit

Cup Slipped

Edit

No Of Application

Edit

No Of Traction

Edit

Vacuum Delivery

Edit

VAGINAL BREECH DELIVERY

Add Element Expand

Consent

Edit

Consultation With Specialist

Edit

Date And Time

Edit

Specialist

Edit

Fetal Heart Rate

Edit

Estimated Birth Weight

Edit

Type Of Breech

Edit

Method of Delivery

Edit

Comments

Edit

Delivery Of After Coming Head

Edit

Comments

Edit

Analgesia

Edit

Comments

Edit

Outcome

Edit

Complication

Edit

INSTRUMENTAL DELIVERY COMPLICATIONS

Add Element Expand

Instrumental Delivery Complications

Edit

Maternal

Edit

Perineal Tear

Edit

Vaginal Tear

Edit

Haematoma

Edit

Estimated Blood Loss (Mls)

Edit

Bladder Or Urethral Injury

Edit

Uterine Or Cervical Injury

Edit

Comments

Edit

Fetal

Edit

Asphyxia

Edit

Cord Blood Ph

Edit

Cephalohaematoma

Edit

Facial Nerve Palsy

Edit

Trauma Of The Soft Tissue Over The Face And Forehead

Edit

Others, Specify

Edit

Comments

Edit

CAESAREAN

Add Element Expand

Date Time Started

Edit

Date Time Finished

Edit

Indication For Surgery

Edit

Anaethesia (Type)

Edit

Type of Caesarean Section

Edit

Skin Incision

Edit

Findings

Edit

Peritonial Cavity

Edit

Lower Segment

Edit

Engagement of Presenting Part

Edit

Placental Site

Edit

Placental Abnormality

Edit

Uterus

Edit

Tubes

Edit

Ovaries

Edit

Liquor

Edit

Abnormalities of Other Structures

Edit

Post Operative Urine

Edit

Blood Stained

Edit

Blood Loss

Edit

Skin Closure

Edit

Difficulties Encountered During Operation

Edit

Baby

Edit

No of babies delivered

Edit

Apgar Score

Edit

1 Min

Edit

5 Mins

Edit

Birth Weight (G)

Edit

Abnormalities

Edit

OPERATIVE PROCEDURE

Add Element Expand

Date Time

Edit

Type Of Anaesthesia

Edit

Gross Specimen

Edit

Cytology

Edit

Pre-operative Diagnosis

Edit

Post-operative Diagnosis

Edit

Type of Operation

Edit

Operative Findings

Edit

MANAGEMENT

Add Element Expand

SIGNATURES

Add Element Expand