Vacuum-Assisted Delivery Risk Assessment Form
Please complete this clinical screening to assess suitability and risks for vacuum-assisted delivery. Use only non-sensitive, delivery-related information. All fields are required for a comprehensive assessment.
Gestational age at delivery
*
Please Select
Less than 34 weeks
34–36 weeks
37–41 weeks
42 weeks or more
Fetal presentation
*
Vertex (head first)
Non-vertex (e.g., breech, face, brow)
Estimated fetal weight
*
Please Select
Less than 2500g
2500–3999g
4000g or more (suspected macrosomia)
Unknown
Indication for vacuum-assisted delivery
*
Prolonged second stage
Non-reassuring fetal heart rate
Maternal exhaustion
Other
Contraindications present
*
Unengaged fetal head
Unknown fetal position
Suspected cephalopelvic disproportion
Bleeding disorder
Face or breech presentation
No contraindications
Parity (number of previous deliveries)
*
Nulliparous (no previous deliveries)
Multiparous (1–4 previous deliveries)
Grand multiparous (5 or more)
Membranes status
*
Intact
Ruptured
Current station of fetal head
*
At or below +2
Above +2
Unknown
Risk factors present (select all that apply)
*
Suspected fetal bleeding disorder
Maternal infection (e.g., HIV, HSV)
Prolonged second stage (>3 hours)
None
Overall clinical suitability for vacuum-assisted delivery
*
Not suitable
1
2
3
4
Highly suitable
5
1 is Not suitable, 5 is Highly suitable
Submit Assessment
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