Delivery Note (Blank Template)

Delivery Note

Dilation onset: patient became fully dilated at __ am/pm (exact time).

Time spent pushing: patient pushed for __ (min/hrs)

Nature of delivery: spontaneous/vacuum assisted/forceps assisted delivery of a (sex) liveborn baby at __ am/pm over an intact/midline episiotomy/2nd degree lacerations perineum from ROA/LOA/OP/LOT position.

Characteristics of newborn: 

  • Apgar score: 1 min score (), 5 min score ()
  • Weight: ___

Pediatricians preset? Yes/no

Delivery of placenta: placenta was delivered spontaneously/with gentle traction/manually. Intact with 1/2/3 vessel cord.

Episiotomy performed? no/1/2/3 epiostomy performed. Repaired with 2-0, 3-0 vicryl/chromic

Cervix/vagina exam: 

  • No lacerations
  • Fundus firm
  • Excellent hemostasis

Rectum exam: no stitch, mucosa intact


Anesthesia: epidural/IV sedation/ lidocaine

Estimated blood loss (EBL):

  • Normal: 400 mL NSVD; hemorrhage > 500 mL
  • Normal: 800 mL LTCS; hemorrhage > 1000 mL

Maternal blood type: 

Rubella status: 


Mr. Stepwards, MS3


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