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Birth Outcome Form

BIRTH OUTCOME FORM – 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. Doulas should complete the form at intake. (* = required)

The forms for prenatal and postpartum visits are here.

Page 1 of 2

Part I

Client Information:

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

No

Type of Medi-Cal*

HealthNet

LA Care

Straight Med-Cal

Medi-Cal ID Number

Insurance (non-Medi-Cal) Name

Insurance Patient ID Number

Client's Race

Hispanic

Non-Hispanic

Fee for Service - Amount

Date Paid or Due

Client's Ethnicity (choose all that apply)

African-American/Black

Asian

Caucasian/European American

Latino

Native American/American Indian

Multiracial

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*

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 Ethnicity (choose all that apply)

African-American/Black

Asian

Caucasian/European American

Latino

Native American/American Indian

Multiracial

Client Medical History

(Link - Confidential Intake Form)

Client's Medical History

Gravida

Para

Tab

Sab

Eab

Prior Cesarean(s)

Yes

No

Number of Cesareans

Did client report depression, anxiety in pregnancy?

Yes

No

Did client report depression, anxeity in postpartum?

Yes

No

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

Yes

No

Please describe

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

Yes

No

Please describe

Birth Outcome Data

Time early labor began

SROM (time)

AROM (time)

Active Labor Time (from 6 cms)

Length of 2nd stage

Hospital Admission Date

Hospital Admission Time

Doula Present?

Yes

No

Induction

Yes

No

Method of Induction

Gestational Age at Induction

Method of Induction

AROM

Cervadil

Pitocin

Stripping Membranes

Cytotec/Misoprostrol

Herbal/Homeopathic

Augmentation

Yes

No

Pain Medication

Yes

No

Pain Medication Type

Epidural

General

Analgesic

Non-Pharmacological Pain Methods Used

Method of Delivery

Vaginal

Cesarean

VBAC

Instrumental Delivery

Yes

No

Type of Instruments

Forceps

Vacuum Extraction

Complications of Delivery

Part I

Client Information:

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

No

Type of Medi-Cal*

HealthNet

LA Care

Straight Med-Cal

Medi-Cal ID Number

Insurance (non-Medi-Cal) Name

Insurance Patient ID Number

Client's Race

Hispanic

Non-Hispanic

Fee for Service - Amount

Date Paid or Due

Client's Ethnicity (choose all that apply)

African-American/Black

Asian

Caucasian/European American

Latino

Native American/American Indian

Multiracial

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*

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 Ethnicity (choose all that apply)

African-American/Black

Asian

Caucasian/European American

Latino

Native American/American Indian

Multiracial

Client Medical History

(Link - Confidential Intake Form)

Client's Medical History

Gravida

Para

Tab

Sab

Eab

Prior Cesarean(s)

Yes

No

Number of Cesareans

Did client report depression, anxiety in pregnancy?

Yes

No

Did client report depression, anxeity in postpartum?

Yes

No

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

Yes

No

Please describe

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

Yes

No

Please describe

Birth Outcome Data

Time early labor began

SROM (time)

AROM (time)

Active Labor Time (from 6 cms)

Length of 2nd stage

Hospital Admission Date

Hospital Admission Time

Doula Present?

Yes

No

Induction

Yes

No

Method of Induction

Gestational Age at Induction

Method of Induction

AROM

Cervadil

Pitocin

Stripping Membranes

Cytotec/Misoprostrol

Herbal/Homeopathic

Augmentation

Yes

No

Pain Medication

Yes

No

Pain Medication Type

Epidural

General

Analgesic

Non-Pharmacological Pain Methods Used

Method of Delivery

Vaginal

Cesarean

VBAC

Instrumental Delivery

Yes

No

Type of Instruments

Forceps

Vacuum Extraction

Complications of Delivery

This field should be left blank

Part II

Postpartum Information

Client Name From Part I

Doula Name From Part I

Mother's Perinatal Depression Score*

Re-hospitalization*

Yes

No

Presence of Maternal Depression*

Yes

No

Presence of Maternal Psychosis*

Yes

No

Breastfeeding*

Yes

No

If Yes

ABM + Breastmilk

Breastmilk Only

ABM Only

Referrals Made?

Yes

No

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

Breastfeeding Initiation*

Yes

No

Infant Feeding Method*

Breastmilk Only

ABM/Formula

ABM/Breastmilk

Newborn Complications

Newborn Re-hospitalization?*

Yes

No

Reason for Readmission?

Client Problems

Psychosocial

Nutritional

Medical

Health Education

This field should be left blank

Contact

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600 Lincoln Ave #92495
Pasadena, CA 91109

Main Phone: 1 (626) 388-2191
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