Doula Certification
Birth Record Form
You will not be turning in this form; it is for training on how to take notes.
Taking notes during a birth can be challenging or distracting. You are not required to take chart notes as a doula. However, having notes from a birth can help you answer questions your clients might have after the birth, help you remember them if they contact you with a subsequent pregnancy, and provide data if you want to track it.
The purpose of this form is to provide a guide for the type of information that can be useful for doulas to capture before leaving a birth. Most doulas are very tired after a birth, and forget details by the time they get home. It is recommended that you take this form with you to the birth. Do not take your notes directly on this form; take notes on a separate notepad as you are able, then review this form prior to leaving the birth to make sure you have captured the information that you want. Once you leave the birth, you may not be able to obtain information that you forgot or didn’t get!
CLIENT PROFILE & HISTORY Client’s Name ______________________________________ Age ______ Name(s) and Relationship(s) of all other member(s) of the labor support team: _______________________________________________________________ Prenatal Status: # of births _____ # of pregnancies _____ # of living children _______ Planned VBAC? Yes / No # of Previous Cesareans _____ # of Previous Vaginal Births/VBACs _________ Place of Birth: Hospital __ Home ___ Freestanding Birth Center __ Other (explain)_____________ City _________________________ State/Province _________ Care Provider: OB ____ Midwife(CPM,CNM,LM) ____ Family Practice MD ____ Other(explain) _____ Client’s preferences for care options for labor, birth and immediate postpartum: |
Labor and Birth
Weeks’ gestation at time of birth ______
Date/time ctx began ______________
Date/time ctx were approximately 5 minutes apart _____________
Date/time of first VE ____________ Dilation/effacement/station ____________
Date/time of approx. start of active labor, as perceived by client ______________ as observed by doula _____________
Approx. length of 1st stage (onset of progressing ctx to 10 cm) ___________
Approx. length of 2nd stage (pushing to birth) _____________
Approx. length of 3rd stage (delivery of placenta) _____________
Baby Information
Date of birth _________ Time of birth _________ Weight _________ Length ______ APGAR: 1 min _____ 5 min _____
After the Birth
Were there any 3rd stage complications? Yes / No
If yes, please explain:
Any immediate health issues or concerns with the birthing person? Yes/No
If yes, explain:
Any immediate health issues or concerns with the baby? Yes/No
If yes, explain:
Transfer to intermediate care or intensive care? ? Yes/No
If yes, explain:
Did the birthing person hold the baby after the birth? Yes / No
If yes, how soon after birth? ____________ For how long? _____________
Did the birthing person breast/chestfeed? Yes / No
If yes, how soon after birth? ___________ For how long? ______________
Describe the first feeding (ex: chest/breast, bottle, unrushed, baby-led, directed by caregiver, nurse or doula – by holding the breast, pressing the baby’s mouth to the nipple, supplementation device, etc.):
Use these common abbreviations listed for your note-taking and when filling out these forms:
Caregiver = CG
client = cl
partner = ptnr
hospital = hosp
birth center = bc
midwife = MW
N/A = not applicable or not available
doctor = dr
contractions = ctx or cx
rupture of membranes = ROM
artificial rupture of membranes = AROM
spontaneous rupture of membranes = SROM
vaginal exam = VE
centimeters = cm
hours = hr
minutes = m
vaginal birth after cesarean = VBA
ultrasound = u/s
