Documentation Checklist for Instrumental Deliveries

With instrumental deliveries, include the following in your note:

  • Evidence of a consent discussion
  • Type of vacuum or forceps
  • Station when applied, verification of position
  • Application site on vertex / verification of application
  • Number of pulls, contractions, and pop-offs with vacuum
  • Comment of descent with traction
  • Pressure: amount and whether decreased between contractions with vacuum
  • Total length of time of application
  • Markings on face, condition of scalp