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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: LABOUR SUMMARY NOTE

LABOUR DETAIL

Labour Onset

Rupture Of Membrane

Not Done

Spontaneous

PPROM

PROM

Artificial

Term

Preterm

Date And Time Rupture Of Membrane

Date And Time

Comments

Beginning Of 1st Stage

Date And Time

Comments

Beginning Of 2nd Stage

Date And Time

Comments

Complete Delivery Of Baby

Complete Delivery Of Baby Method

Please Update Method

Complete Delivery Of Placenta

Date And Time

Comments

Total Duration Of 1st Stage

Time

Comments

Total Duration Of Second Stage

Time

Comments

Total Duration Of Third Stage

Time

Comments

Total Duration of Labour

Time

Comments

Comments On Duration Of Labour

VAGINAL DELIVERY SUMMARY

No. Of Fetus

Gestation At Delivery (Weeks)

Place Of Delivery

Home

OT

Ward

Health Clinic

Government Hospital with Specialist

Labour room

A&E

Private hospital with > 50 beds

Government Hospital without Specialist

Alternative Birthing Centre

University Hospital

Enroute / During Transport

Private hospital / maternity home < 50 beds with specialist

Private hospital / maternity home < 50 beds without specialist

Unknown

Not available

Low risk centre

Others, specify

Analgesia Used

None

Pethidine

Morphine

Other opioids

Epidural

TENS

Entonox

NSAIDS

Others, specify

Procedure Outcome

Failed

Reason for Failure

Forceps

Failure to Apply

Delivery Type

Please Update Method

THIRD STAGE MANAGEMENT

Delivery Of Placenta-Method

Comments

Adherent Placenta

No

Condition Membrane

Please Update Method

Complications At Third Stage

None

Cord Snapped

Retained Placenta

Partial inversion of uterus

Complete inversion of uterus

PPH

Uterine Atony

Others, specify

Comments

Procedures- Third Stage

Manual removal of placenta

Dilatation and Curettage

Manual replacement uterine inversion

O'Sullivan replacement

Surgically replaced

Laparotomy

Hysterectomy

Others, specify

Comments

Oxytocic Used

No

Comments

Type Of Oxytocic

Ergometrine

Syntometrine

Oxytocin

Prostaglandin

Others, specify

Comments

Perineum

Intact

Episiotomy

Perineal tear

Not available

Comments

Repair Done By

Anaes./Analgesia (Perineal Repair)

None

General

Epidural

Spinal

Perineal infiltration with LA

Pudendal block

Entonox

Sedation

Others, specify

Sutures Used

Total Blood Loss (Mls)

Swab Count

Instrument Set

Supplementary

Item

Please Update Method

Particulars of Items left in-situ

MATERNAL CONDITION - POST DELIVERY

Systolic Pressure (Mmhg)

Diastolic Blood Pressure (Mmhg)

Temperature (Degc)

Pulse (Bpm)

Uterus Contracted

YesNo

Size In Weeks

Outcome

Comments

Complication Of Pregnancy / Delivery

Please Update Method

Postpartum Care

Routine Postpartum Care in Ward

Resuscitation

Elective ventilation

ICU care

HDU care

CCU care

Replacement of uterus inversion

Drainage of haematoma

Resuturing

Others, specify

Comments

Delivery Conducted By

Resuscitation Of Mother By

BABY'S RECORD

Baby Records

Please Update Method

Intubated Detail

No

Apgar Score

Please Update Method

DISCHARGE

Discharge Baby To

Lactation Initiation

Baby Attended By

DIAGNOSIS

Diagnosis

POST PARTUM ORDERS

Postpartum Directives

Other Comments

MOTHER

Status

Checklist For Vaginal Delivery

SIGNATURES

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