What do you mean by headings? Are you talking about vaginal delivery ? I have pasted below a fairly standard example although some providers write a note.
Here's a link from ACOG with some info
https://www.acog.org/practice-manag...mentation-requirements-for-vaginal-deliveries
Delivery Note
xxx is a 39 year old now G3P2012 female post-delivery at 40w3d. Pregnancy was significant for AMA, marginal cord insertion, routine prenatal care and Labor.
Mother's Information
Labor Length
1st stage: 3h 32m
2nd stage: 0h 08m
3rd stage: 0h 04m
Lacerations
Episiotomy: None
Perineal laceration: 2nd Degree
Perineal laceration repaired?: Yes
Repair suture: 3-0 Vicryl
Delivery Blood Loss 10/07/23 1100 - 10/07/23 1510
QBL: Vaginal Delivery Volume Hospital Encounter 250 ML
Total 250
xx, Boy xx
Newborn Delivery
Time head delivered: 10/7/2023 14:40:00
Birth date/time: 10/7/2023 14:40:00
Delivery type: Vaginal, Spontaneous
Complications: None
Labor Events
Preterm labor?: No
Rupture date/time: 10/7/2023 1329
Rupture type: Artificial
Fluid color: Clear
Fluid odor: Normal
Labor type: Spontaneous Onset of Labor
Labor allowed to proceed with plans for an attempted vaginal birth?: Yes
Augmentation: AROM
Augmentation date/time: 10/7/2023 1329
Complications: None
Anesthesia
Method: Local
Operative Delivery
Forceps attempted?: No
Vacuum extractor attempted?: No
Shoulder Dystocia
Shoulder dystocia present?: No
Presentation
Presentation: Vertex
Position: Direct Occiput Anterior
Placenta
Placenta delivery date/time: 10/7/2023 1444
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: discarded
Cord
Vessels: 3 Vessels
Complications: None
Delayed cord clamping?: Yes
Cord clamped date/time: 10/7/2023 1441
Cord blood disposition: Discard
Gases sent?: No
Stem cell collection (by provider): No
Apgars
Living status: Living
Apgar Component Scores: 1 min.: 5 min.: 10 min.: 15 min.: 20 min.:
Skin color: 0 1
Heart rate: 2 2
Reflex irritability: 2 2
Muscle tone: 2 2
Respiratory effort: 2 2
Total: 8 9
Apgars assigned by: xx
Resuscitation
Method: None
Measurements
Weight: 4180 g
Weight (lbs): 9 lb 3.4 oz
Length: 55.9 cm
Length (in): 22"
Head circumference: 36 cm
Delivery Providers
Delivering clinician: xx, MD
Provider Role
xx, RN Delivery Nurse
xx Tech
xx Baby Nurse