Midwife _______________________________________ Date / Time _____________________________
Mother's Name________________________ Partner's Name___________________________________
Mother's Address _______________________________________________________________________
EDD ___________________ Mother's Age _____________ Gravida ___________ Para _____________

Prenatal History:
Gestational Age 1st Visit _________________ Weight Gain ___________ Usual BP _______________
Urine _____________ Edema ______________ Pelvimetry ________________ Fundus _____________
Hct / Hgb __________ ABO & Rh ____________ GBS _______ at _______ weeks HbsAg ___________
Comments______________________________________________________________________________
________________________________________________________________________________________


Labor History:
Began labor ________________ Initial Events ________________ Midwife arrived at ______________
General Observation _________________________ Vaginal Exam _____________________________
Comments _____________________________________________________________________________
________________________________________________________________________________________


Course of Labor:
Inactive Labor ____________________ Active Labor _____________ Pushing ___________________
Ruptured Membranes __________________ How? ____________ Meconium? ____________________
Fetal response to labor __________________________________________________________________
Comments _____________________________________________________________________________
________________________________________________________________________________________


Reason for Transport ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________


I, ___________________________ have been informed of all pros and cons regarding my health status and do hereby refuse the emergency transport to a medical facility for further care.

Client/Patient Signature ____________________________ Date _____________ Time _____________