Doula's Name *
Doula's Name
Date of Birth Attended *
Date of Birth Attended
Hospital/ Freestanding Birth Center/ Home
Care Provider
Planned VBAC
Date labor contractions began
Date labor contractions began
Time labor contractions began
Time labor contractions began
Time labor contractions were 5 mins apart
Time labor contractions were 5 mins apart
Spontaneous rupture of membranes
Place
Was meconium present?
Were there any third stage complications?
Was mother breastfeeding?
Time doula arrived
Time doula arrived
Time doula departed
Time doula departed
Baby Information
Date of Birth
Date of Birth
Time of Birth
Time of Birth
Sex
Immediate transfer to intermediate care or NICU?
Labor Progress
Cervical exam #1
Cervical exam #1
Cervical Exam #2
Cervical Exam #2
Cervical Exam #3
Cervical Exam #3
Cervical Exam #4
Cervical Exam #4
Cervical Exam #5
Cervical Exam #5
Medical Intervention/ Procedures
Check all that apply
Select any that apply
Cesarean