Postnatal Data Collection Form

Doula ID

Client ID

Birth ID

Program Type

Pregnancy Number

Birth Number

Delivery Date

Primary Caregiver

Doula Ethnicity Match Client?

Childbirth Class Attendance

During THIS pregnancy. Classes taken anywhere, EM or elsewhere.

Wellness Services During Pregnancy

AcupunctureChiropracticYogaOther

Labor Hours (Admission to Birth)

Labor Hours (Perceived by Parent)

Assigned Doula Attended Birth

Reason

Back-Up Doula Attended Birth

Back-up Doula's Name

Back-up Doula's Last Name

Assigned Doula Labor Hours

Back-up Doula Labor Hours

Birth Attended By

DoulaPartnerOther

Birth Location

Other Birth Location

Only enter the birth location if it is NOT listed in previous question. Home Birth is an option above!

Pregnancy

Birth Method

VaginalPlanned Cesarean (cesarean surgery without any labor)Unplanned Cesarean (cesarean surgery after any amount of labor)

Induction

YesNo

Reason for Induction

Method of Induction

Pain Medications for Labor

Interventions in Labor

NonePitocin augmentationArtificial Rupture of membranes (AROM)Fetal monitoring: dopplerFetal monitoring: intermittent electronicFetal monitoring: continuous electronicFetal scalp electrode (FSE)Intrauterine pressure catheter (IUPC)IV antibioticsIt's very unlikely to be "None".

Type of Vaginal Birth

Spontaneous vaginalInstrumental (vacuum or forceps)EpisiotomyVBAC

Reason for cesarean

Was this a repeat cesarean?

YesNo

Positions for Pushing

Interventions in Immediate Postpartum

NoneIV pitocinIM pitocin (injection in muscle)Repair (stitches for perineal or labial tearing)

Postpartum Hemorrhage

YesNoPossibly, but I'm not sure

Were medicines other than pit given to manage hemorrhage?

Cytotec (rectal)Other anti-hemorrhage medication such as ergometrine/MethergineNo extra anti-hemorrhage medication

Postnatal Data Collection Form

Birth

Postpartum Complications

Baby