On (delivery date, time) this (age, race) female under (epidural, pudendal, local, no) anesthesia delivered a viable (male, female) infant weighing (wt in gm or lb) with APGAR scores of (0-10) and (0-10) at 1 & 5 minutes. Delivery was via (NSVD, VBAC, LTCS, or CS) to a sterile field. (Nuchal cord x coils, reduced). Infant was (bulb, DeeLee) suctioned at (perineum, delivery). Head and shoulder out without difficulty. Cord clamped and cut and infant handed to waiting (pediatrician, nurse). (Cord blood sent for analysis). (Wt.) (intact, fragmented, meconium stained) placenta with (2, 3) vessel cord delivered (spont, with manual extraction) at (time). (Amount) of (IV oxytocin, IM methylergonovine) given. (Ut. Cx, vag., rectum) explored and (MLE, 1° perineal, periuretheral lac, uterine and abdominal incision) repaired in normal fashion with (type) suture. EBL (amount). Pt. taken to RR in stable condition. Infant taken to (newborn nursery, NICU) in stable condition or Pt & baby stable in room #. Delivery done by Dr. (name), assisted by (name).
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