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ICTC International Center for Traditional Childbearing

Birth Evaluation Form
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Please copy this form and fill it out for your births. Mail or email it to the office, so we can update your birth numbers. (To maintain confidentiality, use a code  for the client's name. We suggest using something simple like the client's initials or the date of baby's birth).
 
ICTC LABOR AND BIRTH SUMARY
 

Client’s Name/code________________________________________Parity?________

 

Doula's Name: ______________________________________________________________

 

Date of Baby's Birth: __________________ Boy or Girl________Weight_________apgar________

 

Please circle all that apply.

 

Childbirth Class? Y N                            

 

Pregnancy:                                                                                   

Healthy/well/normal    Strep    Gestational Diabetes     Other _______________                                                                           

Weeks Gestation ________   

 

Birthplace   Home    Birth center        Hospital          Other ________________   

   

Positions for Labor:              Walking/standing      Birth ball      Toilet    Side-lying   Squatting

 Hands/knees    Upright in bed/chair  Supported squat Supine   Other___________

            

Positions for Pushing:            Walking/standing      Birth ball      Toilet    Side-lying   Squatting

 Hands/knees    Upright in bed/chair   Birth stool/chair  Lithotomy  Supine  Other______________

 

 How  long?______________________________________________________________________                                                      

                                              

Caregiver:                                      Interventions:                                Birth:

Midwife                                         Induction @ _____ cm                  Vaginal Birth

Certified Nurse Midwife                  Prostaglandin                             Assisted Vaginal

Family Practice Physician               Cytotec                                           -Forceps

Obstetrician                                      Pitocin                                             -Vacuum extractor

Other ________________                AROM                                         Scheduled Cesarean

                                                        Other ______________                 Unplanned Cesarean

Length of active labor:                     ______________                          Repeat Cesarean

______________________         AROM @ _________ cm                 VBAC

                                                Augmentation @ ______ cm                 Episiotomy?   Y      N

Comfort techniques:                  Electronic Fetal Monitoring              Perineal tear?   Y     N

Massage                                         Continuous @ _____ cm                 Degree 1st  2nd  3rd  4th

Counterpressure                            Intermittent                        

Acupressure                                   External                                           Third Stage:

Birth ball                                       Internal @ ______ cm                      Routine Pitocin IV/IM

Breathing techniques               Amnioinfusion                                                         

Shower/bath                             Doptone/fetoscope                                  Normal blood loss?

Visualizations                          IV/Heparin lock                                      Hemorrhage

Hot/cold therapy                     Catheterization                                       Retained placenta

Music                                        Oxygen by mask                                     How Long?____________

TENS unit                                IV Pain Medications

Aromatherapy                          IV Antibiotics

                                                    Epidural @ ________ cm

                                                     Spinal/Intrathecal

 

 

BIRTH SUMARY PAGE 2

 

Doula's Name: ________________________________________________________________

Client's Code: ________________________________________________________________

Baby's Name: _________________________________________________________________

Please circle all that apply.

Baby:                                                Immediate Postpartum:                      Continued Postpartum:
Healthy/well/normal                      Continuous contact w/ baby              Support in hospital
Meconium                                       Interrupted contact w/ baby             Support at home
        Heavy                                       Length of separation:                        Phone support
        Moderate                                  _____________________                  
        Light                                        Rooming in                                          Infection
Deep suctioning                              Father present                                     Lochia flow:  normal
Early cord clamping                      Siblings present                                   Heavier than normal
Resuscitation required                  Other family/friends                            Baby feeding/gaining well
Birth weight _______________     Breastfeeding                                       Breastfeeding concerns
Apgars ____________________     Bottlefeeding                                       Referral - lactation cons.
NICU?     Y      N                             Other __________________               Referral - caregiver
Birth defect?     Y      N                                                                                Other referral:

How long was hospital stay? Mother___________Baby____________

Stillbirth                                          Placenta given to family?   Y      N               Adoption                                                                                    

Approximate length of First Stage: ____________2nd Stage: _________3rd stage_______________

Time you arrived/labor: ___________________  Time you left: _______________________

Total time you were present/labor & birth: ________________________________________

Postpartum visits: Date/Times ____________________________________________


Total time you were present postpartum: _____________________________________

Postpartum phone support:   Y     N    Total time: _________________________________

Does client have any unmet needs? Housing/clothing/food etc?_______________________

 

Is the baby being seen by doctor or other care-giver?__________ On WIC____ Other?____

 Does the family have insurance?____________

Unusual events/ special things you learned on this birth?__________________________________

 

_____________________________________________________________________________________


                       Please use the back of this sheet if you need more space.

 

 
 

Enter supporting content here

International Center for Traditional Childbearing
Midwifery Mentorship Program
Portland, Oregon