Labor and Delivery Report Form
Use this form to document labor, delivery, newborn outcome, and postpartum details for a birth event.
Patient and Encounter Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Medical Record Number / Patient Reference
Admission Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Attending Clinician Name
*
First Name
Middle Name
Last Name
Facility / Department
*
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Labor Onset and Antepartum Details
Obstetric History Summary
Estimated Due Date
-
Month
-
Day
Year
Date
Gestational Age at Admission
Reason for Admission
*
Labor Onset Type
*
Spontaneous
Induced
Augmented
Rupture of Membranes Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Notable Prenatal Risk Factors or Complications
Labor Course and Delivery Details
Labor progression notes
Analgesia/anesthesia used
None
Epidural
Spinal
Nitrous oxide
Local anesthesia
General anesthesia
Other
Delivery date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Delivery method
*
Vaginal
Assisted vaginal
Cesarean
Other
Delivery method description
Presentation / position (if relevant)
Episiotomy or laceration details
Estimated blood loss (mL)
Newborn Outcome
Number of Newborns Delivered
*
Newborn Sex
Male
Female
Intersex
Not recorded
Birth Weight (grams)
*
Apgar Score at 1 Minute
Apgar Score at 5 Minutes
Cord Blood or Specimen Collected
Yes
No
NICU Transfer
Yes
No
Immediate Newborn Condition / Disposition Summary
Placenta, Complications, and Postpartum Notes
Placenta Delivery Status
*
Delivered intact
Delivered incomplete
Retained
Manually removed
Not applicable
Placenta Condition / Pathology Sent
*
Sent to pathology
Not sent to pathology
Unknown
Maternal Complications
Postpartum hemorrhage
Uterine atony
Laceration
Infection concern
Hypertension
Fever
Other
Medications Given After Delivery
Oxytocin
Misoprostol
Tranexamic acid
Analgesic
Antibiotic
Iron supplement
Other
Postpartum Condition
*
Stable
Monitored closely
Transferred to higher level of care
Critical
Deceased
Discharge / Transfer Destination
*
Home
Postpartum unit
Operating room
Intensive care unit
Another facility
Other
Follow-up Instructions
Additional Remarks
Submit Report
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