History Midwives MANA Statistics Project Data Collection ...

[Pages:8]History

MANA Statistics Project Data Collection Form

Revision 2.0 ? Page 1 of 8

Midwives Representing Alliance the Profession

of Midwifery

of North America

Practice Code1 Midwife Code1 Second Midwife Code1 (OPTIONAL) Third Midwife Code1 (OPTIONAL) Birth Code2 (MIDWIFE'S IDENTIFYING CODE)

History

Client's municipality: ___________________________

State or Province: ______________________________

Population: (CHOOSE ONLY ONE)

| city | suburb

| small town

| rural

Postal (ZIP) Code

Mother's--

age at booking

last grade of high school completed

post secondary formal education (YEARS)

Occupation3: ___________________________________ Race/Ethnic origin:

Caucasian African or Caribbean Native American Asian Hispanic other4: _____________________________________ Special group: (CHECK ANY THAT APPLY) Amish Mennonite Francophone Immigrant of = 10 years other group: ________________________________ Partner status at time of birth: (CHOOSE ONLY ONE) | married couple | unmarried couple | female partner | separated/divorced | single | couple, marital status not known | other status: ________________________________

Partner's-- age

last grade of high school completed post secondary formal education (YEARS) Occupation3: ___________________________________

Family socio/economic level: (MIDWIFE'S EVALUATION)

| lower

| middle

| upper-mid+upper

Y N Previous pregnancy and delivery history Number of previous:

pregnancies

miscarriages5

induced abortions

stillbirths5

live births Number of previous:

home births

birth center births

caesarean sections

VBACs

episiotomies

postpartum hemorrhages

Other previous pregnancy/delivery occurrences: gestation 42 weeks hypertension or pre/eclampsia6 breech forceps/vacuum IUGR/SGA7 birth defect shoulder dystocia other: __________________________________ none

Mother's height: (OR ESTIMATE)

feet

inches OR

centimeters

Mother's prepregnancy weight:

pounds OR

kg

Method of conception: (CHOOSE ONLY ONE) | coitus | artificial insemination | in vitro | other: _____________________________________

Mother reports history of sexual abuse/assault: (CHOOSE ONLY ONE)

| none | before puberty | after puberty | before and after puberty | mother prefers not to answer | midwife did not ask

Practice or Midwife Code1

Birth Code2 (MIDWIFE'S IDENTIFYING CODE)

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Current Pregnancy

Maternal problems: pregnancy-induced hypertension pre-existing hypertension6 pre-eclampsia eclampsia gestational diabetes chronic medical condition8: ____________________ persistent anemia (Hct 160) late or deep decels--1st stage late or deep decels--2nd stage other non-reassuring heart tones that do not respond to therapy: ___________________________________ midwife thinks unusual emotional or social factors may have affected course of labor: ___________________ __________________________________________ none of the above

Cord problems: only 1 or 2 vessels very short around neck tightly around neck 2+ times cord prolapse other: _____________________________________ none

Other complications: shock uterine prolapse placenta previa abruptio placenta anesthesia complications embolism ruptured uterus hematoma other: _____________________________________ none

Midwife's role in hospital: (IF APPLICABLE; CHOOSE ONLY ONE) | not present | primary care giver | assistant to physician | doula/labor coach | not applicable | other: _____________________________________

Practice or Midwife Code1

Birth Code2 (MIDWIFE'S IDENTIFYING CODE)

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Third Stage

Cord clamped: (CHOOSE ONLY ONE) | immediately, before pulsing stopped

| after pulsing stopped

| after placenta delivered

| other: _____________________________________

Cord clamped

minutes after birth

Mother's positions waiting to deliver placenta28: semi-sitting hands and knees squatting standing on side on back stirrups birth stool other: _____________________________________

Method placenta delivered: delivered under water maternal effort controlled cord traction manual removal D&C other: _____________________________________

Prophylactic to avoid hemorrhage: oxytocin shepherd's purse angelica methergine motherwort other: _____________________________________ none

Estimated blood loss: cc (milliliters) OR cups (USE 2 DECIMALS - E.G. 1.00, 2.25)

Action(s) taken for blood loss: pitocin methergine (ergotrate) other drugs: ________________________________ herbs: _____________________________________ IV fluids fundal massage nipple stimulation external bimanual compression internal bimanual compression blood transfusion D&C other: _____________________________________ none

Newborn

(FILL OUT THE NEWBORN SECTION OF FORM FOR EACH BABY)

Sex: | girl

| boy

| ambiguous

Birth weight: grams OR pounds

ounces

Apgar:

1 minute

5 minutes

Y N Any clinical evidence that baby is preterm Y N Any clinical evidence that baby is postterm

Y N Stillbirth5

| death before labor

| during labor

(PROVIDE DETAILS ABOUT DEATH AT END OF FORM)

Y N Birth defects29 (CHOOSE ONLY ONE)

| minor

| serious

| life threatening

Specify: __________________________________

Y N Resuscitation: suction on perineum DeLee bulb suction electric or wall suction tactile stimulation oxygen and PPV free flow oxygen mouth to mouth chest compressions intubation respirator other: __________________________________

Y N Assisted ventilation | 29 minutes

Y N Vitamin K given

| oral

| IM

Y N Eye prophylaxis | erythromycin (ilotycin) | other: __________________________________

Y N Immediate neonatal complications (FIRST 4 HOURS) RDS/Hyaline Membrane Disease meconium aspiration IUGR30 metabolic hypoglycemia or hypocalcemia prematurity seizures birth injuries: ____________________________ non-reassuring heart tones unresponsive to therapy other: __________________________________

Y N Transfer to neonatal intensive care unit

Y N Newborn health problems in first 6 weeks jaundice beyond normal physiologic level

Highest level if measured

(MMOL/LITER)

sepsis/infection respiratory distress failure to thrive seizures other: __________________________________

Practice or Midwife Code1

Birth Code2 (MIDWIFE'S IDENTIFYING CODE)

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Y N Infant in hospital in first 6 weeks Admitted from home or Birth Center birth in: (CHOOSE ONLY ONE)

| ................
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