Birth Outcome Form

BIRTH OUTCOME & POSTPARTUM FORMS – HAPPY MAMA HEALTHY BABY ALLIANCE COMMUNITY DOULA PROGRAM

This information is confidential and will only be used by HMHBA to track outcomes and quality assurance.(* = required)

The forms for prenatal and postpartum visits are here.

Part I

Birth Outcome

Client First Name *

Client Last Name *

Client Address*

Client's Gender *

Female

Non-Binary

Transgender F to M

Male

Client Phone Number*

Client Email Address*

Client Occupation

Social Media (Whatsapp, Facebook, etc)

Client's Date of Birth*

Medi-Cal - Y or N?*

Yes

Type of Medi-Cal

HealthNet

LA Care

Straight Med-Cal

Medi-Cal ID Number

Insurance (non-Medi-Cal) Name

Client ID*

Venice Family Clinic has a unique client ID. It’s their patient record number. *** United Healcare format is the following: UHC in front of the woman's initials. Then first initial, Last initial, woman’s birthday, and year of service. *** For those not receiving services under grants the format is the following: first initial, last initial, woman’s birthday, and year of service. Example: MP941991-2023

Does this client have United Healthcare Insurance?*

Yes

Fee for Service - Amount

Date Paid or Due

Client's Race*

Hispanic

Non-Hispanic

Client's Ethnicity*

Client's Preferred Language(s)*

English

Cantonese

French

Mandarin

Spanish

Tagalog

Vietnamese

Other

Doula Information:

Doula's First Name *

Doula's Last Name *

Doula's Address*

Client's EDD*

Doula's Phone Number*

Doula's Email Address*

Enter your HMHBA email to receive a copy of this form.

Doula's Ethnicity (choose all that apply)

African-American/Black

Asian

Caucasian/European American

Latino

Native American/American Indian

Multiracial

Planned Place of Birth*

Birth Center

Home

Hospital

Name of Medical Provider*

Medical Provider Address

Partner's Information:

Client Partner's First Name

Client Partner's Last Name

Client Partner's Age

Client Partner's Gender

Male

Female

Non-Binary

Transgender

Client Partner's Race*

Hispanic

Non-Hispanic

Client Partner's Ethnicity*

Client Medical History

(Link - Confidential Intake Form for emotional/physical abuse or neglect.)

Is this person a Venice Clinic client?*

Yes

First Birth?*

Yes

Client's Medical History

Gravida

Para

Tab

Sab

Eab

Prior Cesarean(s)

Yes

Number of Cesareans

Did client report depression, anxiety in pregnancy?

Yes

Did client report depression, anxeity in postpartum?

Yes

Did client report lack of respect during labor by care-providers?

Yes

Please describe

Did client report lack of respect in postpartum by care provider?

Yes

Please describe

Birth Outcome Data

Time early labor began

SROM (time)

AROM (time)

Active Labor Time (from 6 cms)

Hospital Admission Date

Hospital Admission Time

Doula Present?*

Yes

Length of 2nd stage

NICU admission*

Yes

Induction

Yes

Method of Induction

Gestational Age at Induction *

Method of Induction*

AROM

Cervadil

Pitocin

Stripping Membranes

Cytotec/Misoprostrol

Herbal/Homeopathic

Augmentation

Yes

Pain Medication

Yes

Pain Medication Type

Epidural

General

Analgesic

Non-Pharmacological Pain Methods Used *

Method of Delivery*

Vaginal

Cesarean

VBAC

Instrumental Delivery*

Yes

Type of Instruments*

Forceps

Vacuum Extraction

Baby's Date of Birth*

Time of Birth*

Weight of Baby*

Length of Baby*

Complications of Delivery*

Is the client happy with our services? Are there any issues? Please describe below.*

This field should be left blank

This is a companion form to the Birth Outcome Form. For a separate Postpartum Visit, use this form.

Part II

Postpartum Information

Date of Postpartum Visit

Client Name From Part I*

Doula Name From Part I*

Doulas email address*

Enter your HMHBA email to receive a copy of this form.

Client ID From Part 1*

Mother's Perinatal Depression Score*

Re-hospitalization*

Yes

Presence of Maternal Depression*

Yes

Presence of Maternal Psychosis*

Yes

Breastfeeding*

Yes

If Yes

ABM + Breastmilk

Breastmilk Only

ABM Only

Referrals Made?

Yes

Referral Reason

Baby's Information

Baby's Name*

Date of Birth*

Time of Birth*

Baby's Gender*

Female

Male

Undetermined

Gestational Age of Infant

Weight of Baby

Length of Baby

APGAR Score

Newborn Complications

Newborn Re-hospitalization?*

Yes

Reason for Readmission?

Breastfeeding

Is the client breastfeeding?*

Yes

Method of Feeding

Breastmilk Only

Mixed Feeding – Breastmilk & Artificial Baby Milk (formula)

Any problems with breastfeeding?

Sore nipples

Low milk supply

Return to Work

Inadequate support

Embarrassment

Engorgement

Tongue Tie/Lip Tie

Other

Reason(s) for discontinuing breastfeeding

Sore nipples

Low milk supply

Return to Work

Inadequate support

Embarrassment

Engorgement

Mastistis

Tongue Tie/Lip Tie

Other

Baby is eating

Artificial Baby Milk (Formula)

Pedialyte

Cow’s Milk

Cereal

Baby Food

Other

Client Problems

Psychosocial

Nutritional

Medical

Health Education

This field should be left blank

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