Operative Vaginal Delivery Assessment Form
Evaluate key clinical aspects of an operative vaginal delivery case.
Indication for Operative Vaginal Delivery
*
Please Select
Prolonged second stage
Fetal distress
Maternal exhaustion
Medical indication (e.g., cardiac, neurological)
Other
Instrument Used
*
Vacuum
Forceps
Both
Fetal Head Position at Application
*
Occiput anterior
Occiput posterior
Occiput transverse
Other
Station of the Fetal Head
*
Please Select
Low (+2)
Outlet
Midpelvic (+1 to +2)
Other
Degree of Molding/Caput
*
None
Mild
Moderate
Severe
Number of Traction Attempts
*
Maternal Complications
*
None
Perineal trauma
Postpartum hemorrhage
Infection
Other
Neonatal Complications
*
None
Scalp injury
Cephalohematoma
Low Apgar score
NICU admission
Other
Operator Experience Level
*
Resident
Fellow
Attending
Overall Outcome Assessment
*
1
2
3
4
5
Submit Assessment
Should be Empty: