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MoonDragon's Pregnancy Information
MATERNAL BIRTH RECORD WORKSHEET
Client File Forms




MATERNAL BIRTH RECORD WORKSHEET



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: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________







RELATED LINKS

MoonDragon's Client Forms Index
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Index
MoonDragon's Womens Pregnancy Health Information Index
MoonDragon's Pediatric Information Index
MoonDragon's Parenting Information Index
MoonDragon's Nutrition Information Index






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Aromatherapy
Healing Baths For Colds
Aromatherapy
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Using Essential Oils


AROMATHERAPY: HERBAL & CARRIER OILS DESCRIPTIONS & USES


Almond, Sweet Oil
Apricot Kernel Oil
Argan Oil
Arnica Oil
Avocado Oil
Baobab Oil
Black Cumin Oil
Black Currant Oil
Black Seed Oil
Borage Seed Oil
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