Scheduling Form for Inductions and Cesarean Sections



Scheduling Form for Inductions and Cesarean Sections

Call: _______________ Fax: _________________

Name __________________________________________ Phone ________________________________

OB Provider _____________________________________________ G/P ___________________________

Type of Delivery Planned Induction C/S Desired Date/Time ______________________________

DATING

EDC ______________ Gestational Age at Date of Induction or C/S ____________________ week + day)

EDC Based on 1. LMP 2. First trimester utz 38 wks)

IUGR Elective Induction

Non-reassuring fetal (>39 wks)

Status Patient choice/social

Isoimmunization Distance

Fetal malformation Other: ___________________

Twin with complication

Description Details: ____________________________________________________________________

CERVICAL EXAM (for inductions)

Date of Exam: ________________ (within 7 days of date of induction)

Bishop Score: circle each element of the exam below and add: Total Score: _____________

|Score |Dilation |Effacement |Station |Consistency |Position | | |

| | | | | | | |This section is used only by |

| | | | | | | |those hospitals using cervical |

| | | | | | | |exam criteria for scheduling |

| | | | | | | |inductions |

|0 |Closed |0-30% |-3 |Firm |Posterior | | |

|1 |1-2 |40-50% |-2 |Medium |Midposition | | |

|2 |3-4 |60-70% |-1.0 |Soft |Anterior | | |

|3 |5-6 |80% |+1. +2 |-------- |-------- | | |

SCHEDULING OFFICE USE Procedure NOT Scheduled:

Scheduled by: ___________________________ Confirmed Date/Time: _______________

Referred to Dept Chair Prenatal/Record presenting LD: Yes

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