Data Collection Form - Pals Doulas

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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  

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