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ICTC International Center for Traditional Childbearing

Birth Evaluation Form
About Us
Our Services
ICTC Doulas
Contact Us
Meet Our Staff
Study Pages
Meeting Schedule
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).

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                            



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






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.



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International Center for Traditional Childbearing
Midwifery Mentorship Program
Portland, Oregon