Labor and Delivery Complication Record Form
Use this form to document labor and delivery complication events. The Labor and Delivery Complication Record Form is intended for internal event documentation only and is not suitable for collecting sensitive health information.
Date and Time of Complication
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Age (Years)
*
Gravida/Para Status
Type of Complication
*
Please Select
Hemorrhage
Pre-eclampsia/Eclampsia
Obstructed Labor
Fetal Distress
Infection
Uterine Rupture
Shoulder Dystocia
Other
Brief Description of Complication
*
Interventions Performed
*
Outcome for Patient
*
Please Select
Stable
Transferred to Higher Care
Surgical Intervention Required
Other
Outcome for Newborn
Please Select
Stable
NICU Admission
Resuscitation Required
Other
Attending Staff Initials
*
Location (Unit/Room)
Submit Record
Should be Empty: