Documentation: Active Labor Client name * First Name Last Name Date notified * MM DD YYYY Time notified * Hour Minute Second AM PM Notified by * client client's partner client's relative client's friend doula colleague management L&D staff other Date of doula arrival * MM DD YYYY Time of doula arrival * Hour Minute Second AM PM Delivery facility * Support people present * Upon arrival, client's comfort level was * 5 - very comfortable (normal) 4 - comfortable 3 - somewhat uncomfortable 2 - uncomfortable 1 - very uncomfortable Had the client received a recent exam? * yes no Dilation 0 1 2 3 4 5 6 7 8 9 10 Effacement 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pelvic station -3 -2 -1 0 +1 +2 +3 Type of delivery * vaginal birth, forceps vaginal birth, vacuum vaginal birth, forceful vaginal birth, unassisted cesarean birth, scheduled cesarean birth, non-urgent cesarean birth, urgent cesarean birth, emergency vaginal birth after cesarean (VBAC) Explanation * Non-clinical comfort measures used * birth ball peanut ball aromatherapy hot compress cold compress shower tub vibrating massager manual massage counterpressure distraction TENS unit hypnosis/guided imagery sound/music other none Clinical interventions used * nitrous oxide sterile water injections IV - antibiotics IV - fluids IV - NSAIDs IV - narcotics epidural none other Induction methods * misoprostol (cytotec) dinoprostone (cervidil) foley pump (balloon) artificial oxytocin (pitocin) natural oxytocin castor oil membrane sweep manual rupture of membranes other not induced Reason for induction Augmentation methods * misoprostol (cytotec) dinoprostone (cervidil) foley pump (balloon) artificial oxytocin (pitocin) natural oxytocin castor oil membrane sweep manual rupture of membranes other not augmented Reason for augmentation Services provided postpartum * direction in skin-to-skin support with breastfeeding (initial latch) transfer to postpartum unit arranging postpartum meal informing relatives of baby's arrival other none Explanation Complications observed * hemorrhage shoulder dystocia breech chorioamnionitis non-reassuring fetal heart rate maternal hypertension maternal hypotension other none Explanation Overall, how closely was the birth plan followed? * 5 - everything went according to plan 4 - there were few, minor changes 3 - there were multiple changes 2 - there were several major changes 1 - the birth experience did not go according to plan How did the client react to the aforementioned changes? Gestation at delivery * Sex of infant * female male Date of delivery * MM DD YYYY Time of delivery * Hour Minute Second AM PM Were you present during the delivery of the fetus? * yes no Explanation Name of infant * Date of doula departure * MM DD YYYY Time of doula departure * Hour Minute Second AM PM Total number of active labor support hours provided * Follow-up plans * doula will call client within 24 hours client will call doula within 24 hours Signed (doula provider) * Your changes have been saved.
