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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