DATA COLLECTION FORM
Place a check in each appropriate box. Use one form per birth. Make additional copies as needed.
Doula'ʹs Name: _________________________________
1ST STAGE INTERVENTIONS:
Doula'ʹs Labor Hours: ________ Labor Length: ______
! Induction Method ______________________
Mother'ʹs Age: _________ Mother'ʹs Initials: _________
! Artificial Rupture of Membranes ______cm
Pregnancy #: ____ Birth #: _____ Date: _____________
! IV or Heplock
! Mom restricted to bed
REFERRAL SOURCE and PAYMENT:
! Pitocin @ ___________cm
! PALS Doulas
! Monitoring: EFM___ IUPC___FSE___
! Private Pay
! Other: _____________________________
! Other
LABOR COMPLICATIONS: o None
ETHNICITY:
! Meconium present
o Fetal distress
! Asian
o African American
! Persistent occiput posterior o Breech
! Caucasian
o Hispanic
! Postpartum hemorrhage
o Hemorrhage
! Native American
! Retained placenta
o Lacerations
! Other: ____________________________
! Episiotomy
ATTENDED BY:
MEDICATIONS:
o None
! Married, partner present/not present
! Analgesia: _________________ @ _____cm
! Single, accompanied, male or female
! Epidural: ___________________@ ____ cm
! Single, unaccompanied
! Other: __________________________
PLACE OF BIRTH:
METHOD OF BIRTH:
! Home
o Hospital o Birth Center
! Spontaneous vaginal
CAREGIVER:
! Water birth
! Midwife
! Forceps
o Vacuum
! OB Doctor
! Planned cesarean section
! Combination
! Unexpected cesarean section
! Family Practice Doctor
COMFORT MEASURES:
PREGNANCY:
! Patterned breathing
! Normal
! Massage
! Gestational Diabetes
! Acupressure
! Pregnancy Induced Hypertension (PIH)
! Hydrotherapy
! Post Date > 42 weeks
! Verbal encouragement
! Premature < 37 weeks
! Guided imagery/Visualization
! Other: ______________________________
! Birth tools: ball, cold/hot packs, etc
! Other: ___________________________
CHILDBIRTH EDUCATION CLASSES:
! Yes
o No
B
’
O
:
Normal
o
ABY
S
UTCOME
o Birth Weight
o Premature
VAGINAL BIRTH AFTER C-‐‑ S ECTION:
o Apgars: _________ o Stillbirth
! Successful
o Attempted
o Breastfed: _______ o NICU
o Other: ___________________________
Mail completed form to: PALS Doulas, 2524 16th Ave. S., Suite 207B, Seattle, WA 98144.
Data Collection Form 9.16