胎头吸引术知情同意书.docx

胎头吸引术知情同意书

姓名：__________性别：女年龄：__________病案号：__________

孕周：_____周_____天孕次_____产次_____预产期：__________

入院诊断：________________________________________________

当前分娩阶段：□第一产程□第二产程胎膜状态：□已破□未破破膜时间：__________

胎方位：__________胎头下降水平：S_____预估胎儿体重：__________g

胎心监护情况：□一类图形□二类图形□三类图形羊水性状：□清□I度污染□II度污