BIRTH RECORD WORKSHEET (MATERNAL)
Mother's Name:________________________ Father's Name:___________________________
Mother's Birth Date: ____________Age:____ Father's Birth Date: ___________Age:________
Mother's Address:______________________ Father's Address:_________________________
Mother's Phone:________________________ Father's Phone:__________________________
Gravida: _________ Para:_________ EDD:_________ Weeks Gestation:_________________
Birth Attendants: _______________________________________________________________
Others Present:________________________________________________________________
_______________________________________________________________________________
Labor Summary:
Labor began at:_____ Spontaneous:____ Induction:____ Method of Induction:____________
Length of Labor:
1st Stage:___________________________________________________
2nd Stage:___________________________________________________
3rd Stage:___________________________________________________
4th Stage:___________________________________________________
Membranes ruptured at:______SROM_____AROM_____Dilation_____cm. Effacement_____%
Amniotic fluid appearance & odor:________________________________________________
Fetal Presentation at last exam:_____ in 1st Stage:____2nd
Stage:_____ Crowning:________
Was presentation altered during labor______ Method used:___________________________
Unusual occurrences: ___________________________________________________________
Comments:____________________________________________________________________
______________________________________________________________________________
Placental Summary:
Signs of placental separation (include approximate time):
Lengthening of the cord: ________________ Time: _______________________________
Cord stops pulsating: ___________________ Time: ______________________________
Gush of blood: _________________________ Time: ______________________________
Rise and motility of the uterus: ____________Time: _______________________________
Placenta delivered at (time):___________Shultz:_____________ Duncan:_____________
Placenta Examination by:_________________________ Time:______________________
Cord Length: ______inches. Number of vessels: _______ Knots: _______ Size:_______
Cord Point of Attachment: ____________ Abnormalities:___________________________
Placenta Weight: ___________ lbs ___________ oz. (Drawing of placenta and cord)
Type: Normal_____________________________
Succenturiata (extra lobe) _______________
Bipartita (2 lobed @ cord) _______________
Tripartita (3 lobed @ cord) ______________
Circumvallata (infarct memb)_____________
Staining:_________________________________
Infarcts:__________________________________
Calcifications:_____________________________
Fat Deposits:______________________________
Cotyledons:_______________________________
General Conditions:________________________
Abnormalities:_____________________________
Membranes: Chorion__________________ Amnion_______________________________
Membrane Abnormalities: ________________________________________________________
Comments: ____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Perineal Examination:
Episiotomy performed: ____ Type: _____ Degree: (1st)
(2nd) (3rd) (4th) Tear past incision? ____
Reason for Episiotomy:___________________________________________________________
External Lacerations: ______ Number of Sutures Required: _____
Description:____________________________________________
_______________________________________________________
_______________________________________________________
Internal Lacerations: ______Number of Sutures Required: ______
Description:____________________________________________
_______________________________________________________
_______________________________________________________
Vaginal Exam: ___________________________________________
Reason for Lacerations: ___________________________________
________________________________________________________
Cervical Exam: ___________________________________________
Reason for Lacerations: ___________________________________
________________________________________________________
________________________________________________________
Anesthetic Administered: __________ Type: __________________
Using sterile technique, check for tears: ______________________
Describe Findings: ________________________________________
________________________________________________________
________________________________________________________
Repair done by:__________________________________________
Uterine Summary:
Length of 3rd Stage: _______________ Was it spontaneous? ________ Induced? __________
If induced, describe method(s) used:_______________________________________________
Estimated blood loss: (before expulsion) _______________ (after expulsion) ______________
Did baby breastfeed to aid placental contractions & expulsion?_________________________
Comments:_____________________________________________________________________
_______________________________________________________________________________
Herbs/homeopathic aids used: ____________________________________________________
Medications used: _______________________________________________________________
Manual methods used: ___________________________________________________________
Uterine response to fundal massage:_______________________________________________
Fundal Firmness check: (time) __________Comments:_________________________________
(External version)
Time: __________ Comments: _____________________________________________________
Time: __________ Comments: _____________________________________________________
Time: __________ Comments: _____________________________________________________
(Internal-bimanual version)
Time: __________ Comments: _____________________________________________________
Time: __________ Comments: _____________________________________________________
Did mother and her partner receive instruction on how to continue uterine tone
checks over the next several hours?__________________________________________________________
Comments:____________________________________________________________________
_______________________________________________________________________________
Was mother a VBAC? __________Comments?________________________________________
Any problems occurring with old suture scar internally? ___________ Externally? __________
Further comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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MoonDragon's Client Forms Index
