History Midwives Representing MANA Statistics Project the Profession Data Collection Form Alliance of Midwifery of North America Revision 2.0 – Page 1 of 8

Practice Code1 Y N Previous and delivery history Midwife Code1 Number of previous: Second Midwife Code1 (OPTIONAL) miscarriages5 Third Midwife Code1 (OPTIONAL) induced Birth Code2 (MIDWIFE’S IDENTIFYING CODE) stillbirths5 live births Number of previous: History home births Client’s municipality: ______birth center births State or Province: ______Population: (CHOOSE ONLY ONE) caesarean sections | city | suburb | small town | rural VBACs Postal (ZIP) Code Mother’s— postpartum hemorrhages age at booking Other previous pregnancy/delivery occurrences: last grade of high school completed gestation <37 weeks gestation >42 weeks post secondary formal education (YEARS) hypertension or pre/eclampsia6 3 Occupation : ______breech Race/Ethnic origin: forceps/vacuum Caucasian IUGR/SGA7 African or Caribbean birth defect Native American Asian other: ______Hispanic none other4: ______Mother’s height: (OR ESTIMATE) Special group: (CHECK ANY THAT APPLY) Amish feet inches OR Mennonite centimeters Francophone Mother’s prepregnancy weight: Immigrant of <10 years pounds OR kg Immigrant of >= 10 years Method of conception: (CHOOSE ONLY ONE) other group: ______| coitus Partner status at time of birth: (CHOOSE ONLY ONE) | artificial insemination | married couple | in vitro | unmarried couple | other: ______| female partner Mother reports history of sexual abuse/assault: | separated/divorced (CHOOSE ONLY ONE) | single | none | couple, marital status not known | before puberty | other status: ______| after puberty Partner’s— | before and after puberty age | mother prefers not to answer last grade of high school completed | midwife did not ask post secondary formal education (YEARS) Occupation3: ______

Family socio/economic level: (MIDWIFE’S EVALUATION) | lower | middle | upper-mid+upper Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 2 of 8

Other prenatal tests: Current Pregnancy routine blood work12 Maternal problems: triple screen pregnancy-induced hypertension pre-existing hypertension6 pre-eclampsia non-stress test eclampsia glucose (specify test & week ______) gestational diabetes Group B Strep chronic medical condition8: ______other: ______persistent anemia (Hct<30 or Hgb<10 g/dl)9 none Rh sensitized Prenatal classes: (CHOOSE ONLY ONE) other: ______| none | previous pregnancy none | this pregnancy | both Infection: Payment: (CHOOSE ONE PRIMARY; ONE SECONDARY IF genital herpes APPLICABLE) chlamydia Primary Secondary urinary tract infection | client paid | client paid yeast | Blue Cross/Shield | Blue Cross/Shield gonorrhea | commercial insurance | commercial insurance GBS+10 | HMO (other prepay) | HMO (other prepay) other: ______| Champus | Champus none | Medicaid | Medicaid Bleeding in trimesters: | universal gov’t hlth. ins. | universal gov’t hlth. ins. 1st | none | light | heavy | other: ______| other: ______2nd | none | light | heavy Y N Tobacco, alcohol or recreational drugs 3rd | none | light | heavy Y N Cigarettes during pregnancy Fetal problems: months of cigarettes suspected IUGR Average of cigarettes/day in those months birth defect: ______intrauterine death Y N Alcohol during pregnancy oligohydramnios Average of drinks per month hydramnios Marijuana/THC/hashish: (CHOOSE ONLY ONE) other: ______| never | occasional | regular none Other recreational drugs: (CHOOSE ONLY ONE) | never | occasional | regular Y N Midwife perceives emotional/social problems11: Drug type: ______describe:______Drugs prescribed: Prenatal Care: antibiotics week (FROM LMP) any prenatal care began antifungals week (FROM LMP) midwife prenatal care began antiemetics antihypertensives Number of prenatal visits: other prescription drugs: ______with a midwife no prescription drugs estimated with general/family practice physician Mother’s overall nutrition: estimated with obstetrician (MIDWIFE’S ASSESSMENT; CHOOSE ONLY ONE) estimated with naturopath/herbalist/homeopath | excellent | good | fair | poor estimated with chiropractor Diet during pregnancy13: other: ______Primary Secondary | “meat & potatoes” | “meat & potatoes” Y N Ultrasound | whole foods and meat | whole foods and meat Total number of ultrasounds in each trimester: | junkfood | junkfood 1st 2nd 3rd | ovo-lacto vegetarian | ovo-lacto vegetarian Number in each trimester midwife felt unnecessary but | vegan vegetarian | vegan vegetarian requested by client: 1st 2nd 3rd | macrobiotic | macrobiotic Number midwife felt unnecessary but requested by | other: ______| other: ______Y N Mother restricted calories to limit weight gain physician: 1st 2nd 3rd Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 3 of 8

Activity level during majority of pregnancy: Y N Home birth was not or could not have been initi- (CHOOSE ONLY ONE) ated or was outside of your home birth protocol | very active | active | sometimes active | sedentary (ANSWER FOR ALL CLIENTS)14 Reasons: Y N Perineal massage or stretching: preterm/post-term Estimated number of times during 3rd trimester breech or malpresentation Y N Herbs or homeopathy during pregnancy undiagnosed breech Herbs or homeopathy (INDICATE TYPE, ESTIMATED NUMBER multiple birth OF TIMES TAKEN EACH TRIMESTER AND REASONS FOR USE) hypertension ______1st 2nd 3rd anemia Reason: ______diabetes pre-eclampsia/eclampsia ______1st 2nd 3rd placenta previa/abruptio Reason: ______retained placenta ______1st 2nd 3rd other: ______Reason: ______Reasons for choosing intended place of birth (as stated ______1st 2nd 3rd by mother)15: Reason: ______Primary Reason Other Reasons If more used, describe: ______(CHOOSE ONLY ONE)(CHECK ANY THAT APPLY) ______| “high risk” “high risk” ______| partner preference partner preference ______| dislikes hospitals dislikes hospitals ______| spiritual spiritual Y N Breech after 28 weeks gestation | desire for natural birth desire for natural birth 1st time breech noticed (WEEK FROM LMP) | effect on baby effect on baby | control control Last time breech (WEEK FROM LMP) | social pressure social pressure Breech turning exercises (NUMBER OF TIMES) | cost cost External cephalic version (ECV): | safety safety attempts : successes | family unity family unity ECV by midwife : | atmosphere atmosphere ECV by physician : | other: ______other: ______Other procedures to turn the breech: Planned site of birth in last trimester: (CHOOSE ONLY ONE) 1= ______| home | hospital 2= ______| birth center | undecided 3= ______| other: ______

Began labor intending to deliver: (CHOOSE ONLY ONE) | at home | in the hospital Birth Data | in a birth center | undecided Y N Woman stopped using this midwife for primary | other: ______care before labor at term began Reason stopped: Y N Decision to transport at first assessment in labor miscarriage5 Place of birth: (CHOOSE ONLY ONE) preterm | home stillbirth | freestanding birth center referral for complications | labor/deliver in same hospital room client moved | labor/deliver in separate hospital rooms client chose birth center | operating room client chose hospital | other: ______changed midwives Gestation: (MIDWIFE’S BEST ESTIMATE BEFORE BIRTH BASED ON ALL cost AVAILABLE INFORMATION) other: ______Weeks Days week from LMP when midwife care stopped (FOR MISCARRIAGE/STILLBIRTH/PREMATURITY, COMPLETE AS Mother certain about dates: (CHOOSE ONLY ONE) MUCH OF THE FORM AS POSSIBLE)5 | yes | fairly | not certain Weight gain during pregnancy: Date of miscarriage: (MM/DD/YY) pounds OR kg Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 4 of 8

Y N Plateaus, reversals, anterior lip or pushing before Labor full dilation Y N Induction and augmentation of labor 1st stage plateaus: (SAME CM. ASSESSMENT FOR >2 HRS) Induction Augmentation (CHECK ANY THAT APPLY) Dilation (cm) Hours Minutes ARM <5cm ARM >5cm Dilation (cm) Hours Minutes prostaglandin Dilation (cm) Hours Minutes oxytocin Dilation (cm) Hours Minutes nipple stimulation Cervical reversal21 from: cm to cm castor oil Cervical reversal was: (CHOOSE ONLY ONE) stripping membranes | before transport intercourse | after transport enema | after waters broke caulophyllum | after other situation (E.G. MOTHER-IN-LAW ARRIVED) blue/black cohosh ______pulsatilla Anterior lip longer than 1 1/2 hours22: evening primrose oil other: ______Hours Minutes From last procedure to active labor: Pushing before full dilation: Days Hours Minutes Hours Minutes 2nd stage plateau: (FULL DILATION AND NO PUSHING)23 Length of early labor16: Hours Minutes Days Hours Minutes Length of active 1st stage17: Presentations of potential concern: Active 1st Stage Second Stage Days Hours Minutes posterior posterior Length of 2nd stage (FULL DILATION)18: breech breech Days Hours Minutes head deep transverse head deep transverse Length of 3rd stage: transverse lie transverse lie Hours Minutes asynclitism asynclitism face face Approximate total time the woman in labor had a: brow brow Midwife present before birth19: other: ______other: ______Days Hours Minutes none none Midwife present after birth: Baby’s position at delivery: (CHOOSE ONLY ONE) Hours Minutes | anterior | head deep transverse Rupture of membranes: | posterior | transverse lie Y N “Hind Leak” which tested positive | frank breech | face Approximate time between “hind leak” and birth20: | footling breech | brow Days Hours Minutes | complete breech Approximate time between rupture and birth: Mother’s mobility during active 1st stage: Days Hours Minutes (CHOOSE ONLY ONE) | mother changed positions frequently Number of babies: | mother didn’t choose to take many positions | movement restricted by anesthetic or attachments Date and time of birth: (ENTER FOR EACH BABY) | movement restricted by staff (MM/DD/YY) Mother’s mobility during 2nd stage: (CHOOSE ONLY ONE) AM/PM (CIRCLE ONE) | mother changed positions frequently | mother didn’t choose to take many positions | movement restricted by anesthetic or attachments | movement restricted by staff

Baby born under water: (CHOOSE ONLY ONE) | yes | no | intended, but not born under water Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 5 of 8

Mother’s final delivery position: (CHOOSE ONLY ONE) Y N Perineal, labial, cervical or vaginal trauma | semi-sitting | on back : (CHOOSE ONLY ONE) | hands and knees | stirrups | none | squatting | birthing stool | mediolateral by physician | standing | deBy birth stool | median by physician | on side | McRoberts thigh hyperflexion | mediolateral by midwife | other: ______| median by midwife Number of vaginal exams: | other: ______Perineal tear and degree: (CHOOSE ONLY ONE) during 1st stage during 2nd stage | no tear Auscultation in active 1st stage: (CHOOSE ONLY ONE) | 1st degree | every 15 minutes | more often | less often | 2nd degree | 3rd degree (into anal sphincter) Auscultation in 2nd stage: (CHOOSE ONLY ONE) | 4th degree (into rectal mucosa) | after every contraction Labial tear: (CHOOSE ONLY ONE) | after every 2nd contraction | none | slight | required suturing | every 5 minutes | other: ______Repair of episiotomy or tear Other trauma requiring repair: ______Y N Use of water or low intervention pain relief Uses of water in: Early labor Active 1st 2nd stage Complications none Y N bath/pool Hospital or birth center procedures shower Electronic fetal monitor: jacuzzi 1st stage other: ______2nd stage Massage: Other monitoring: counter pressure fetal scalp sample body massage cord blood gases other: ______Pain relief: Other pain relief: spinal TENS demerol intracutaneous sterile water nubain acupuncture nitrous oxide other: ______general other: ______Y N Nourishment, IV, medication, herbs, homeopathy Y N Epidural during labor Time between getting epidural and birth: Nourishment, 1st stage: (CHOOSE ONLY ONE) Hours Minutes | nothing | only fluids or jello | solid food Dilation in cm when epidural was given: Nourishment, 2nd stage: (CHOOSE ONLY ONE) | nothing | only fluids or jello | solid food cm Y N Forceps Y N IV initiated in 1st stage Y N Y N IV initiated in 2nd stage Y N Cesarean section Y N Medications in 1st stage: ______Reason(s) for C-section: Y N Medications in 2nd stage: ______failure to progress Y N Herbs/Homeopathy in 1st stage: ______fetal distress Y N Herbs/Homeopathy in 2nd stage: ______meconium not vertex lie Active perineal guidance in 2nd stage: maternal exhaustion manual support other: ______massage At time decision made, midwife thought cesarean hot compresses was warranted: (CHOOSE ONLY ONE) oils/lubricants | yes | probably | possibly | not warranted verbal guidance flexion/counterpressure of head24 other: ______none Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 6 of 8

Y N Transport from planned home or birth center birth Y N Meconium Did the midwife consider transport urgent? Stage when meconium noticed: (CHOOSE ONLY ONE) (CHOOSE ONLY ONE) | 1st stage | 2nd stage | 3rd stage | yes | no Density: (CHOOSE ONLY ONE) Transport by: (CHOOSE ONLY ONE) | thin | moderate | thick | car Consistency: (CHOOSE ONLY ONE) | ambulance | particulate | well dissolved | other: ______Color: (CHOOSE ONLY ONE) Labor stage at transport: (CHOOSE ONLY ONE) | yellow | light green | dark green | brown | first | second | third | postpartum Color darkened during labor Length of time before or after birth that decision Other factors of delivery: to transport was made: compound presentation27 Hours Minutes fetal bradycardia (PROLONGED FHT < 110) Time from decision to arrival at hospital: fetal tachycardia (PROLONGED FHT > 160) Hours Minutes late or deep decels—1st stage Reason(s) for transport: late or deep decels—2nd stage Primary Secondary other non-reassuring heart tones that do not respond to (CHOOSE ONLY ONE): (CHOOSE ONLY ONE): therapy: ______| Pain relief | Pain relief midwife thinks unusual emotional or social factors may | failure to progress | failure to progress have affected course of labor: ______| sustained fetal distress | sustained fetal distress ______| malpresentation | malpresentation none of the above | thick meconium | thick meconium Cord problems: | abruptio/previa | abruptio/previa only 1 or 2 vessels | hemorrhage | hemorrhage very short | retained placenta | retained placenta around neck tightly | maternal exhaustion | maternal exhaustion around neck 2+ times | baby’s condition: | baby’s condition: cord prolapse ______other: ______| other: ______| other: ______none Midwife and client’s reception at hospital: Other complications: (CHOOSE ONLY ONE) shock | supportive | indifferent | unsupportive | hostile uterine prolapse Y N Shoulder dystocia25 placenta previa Dystocia was: (CHOOSE ONLY ONE) abruptio placenta | minor | moderate | severe anesthesia complications Resolution techniques tried: (NUMBER IN ORDER USED) embolism restitution of head ruptured hematoma 26 hyperflexion of thighs other: ______supra pubic pressure none

delivery of posterior shoulder Midwife’s role in hospital: (IF APPLICABLE; CHOOSE ONLY ONE) hands and knees26 | not present corkscrew maneuver | primary care giver | assistant to physician rotation to an oblique position | doula/labor coach delivery of posterior arm | not applicable episiotomy | other: ______other: ______Minutes between head and shoulders Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 7 of 8

Birth weight: Third Stage grams OR Cord clamped: (CHOOSE ONLY ONE) pounds ounces | immediately, before pulsing stopped | after pulsing stopped Apgar: | after placenta delivered 1 minute 5 minutes | other: ______Y N Any clinical evidence that baby is preterm Cord clamped minutes after birth Y N Any clinical evidence that baby is postterm Mother’s positions waiting to deliver placenta28: Y N Stillbirth5 semi-sitting | death before labor | during labor hands and knees (PROVIDE DETAILS ABOUT DEATH AT END OF FORM) squatting standing Y N Birth defects29 (CHOOSE ONLY ONE) on side | minor | serious | life threatening on back Specify: ______stirrups Y N Resuscitation: birth stool suction on perineum other: ______DeLee Method placenta delivered: bulb suction delivered under water electric or wall suction maternal effort tactile stimulation controlled cord traction oxygen and PPV manual removal free flow oxygen D&C mouth to mouth other: ______chest compressions intubation Prophylactic to avoid hemorrhage: respirator oxytocin other: ______shepherd’s purse angelica Y N Assisted ventilation methergine | <10 minutes | 11-29 minutes | >29 minutes motherwort Y N Vitamin K given other: ______| oral | IM none Y N Eye prophylaxis Estimated blood loss: | erythromycin (ilotycin) cc (milliliters) OR | other: ______

cups (USE 2 DECIMALS - E.G. 1.00, 2.25) Y N Immediate neonatal complications (FIRST 4 HOURS) Action(s) taken for blood loss: RDS/Hyaline Membrane Disease pitocin meconium aspiration 30 methergine (ergotrate) IUGR other drugs: ______metabolic hypoglycemia or hypocalcemia herbs: ______prematurity IV fluids seizures fundal massage birth injuries: ______nipple stimulation non-reassuring heart tones unresponsive to therapy external bimanual compression other: ______internal bimanual compression Y N Transfer to neonatal intensive care unit blood transfusion Y N Newborn health problems in first 6 weeks D&C jaundice beyond normal physiologic level other: ______none Highest level if measured (MMOL/LITER) sepsis/infection respiratory distress Newborn failure to thrive seizures (FILL OUT THE NEWBORN SECTION OF FORM FOR EACH BABY) other: ______Sex: | girl | boy | ambiguous Practice or Midwife Code1 Birth Code2 (MIDWIFE’S IDENTIFYING CODE) Page 8 of 8

Y N Infant in hospital in first 6 weeks Other postpartum complications: Admitted from home or Birth Center birth in: late hemorrhage (AFTER 24 HRS) (CHOOSE ONLY ONE) hypertension | <6 hours | 6 to 24 hours | days cervical/uterine prolapse 9 Initial hospital stay: (CHOOSE ONLY ONE) anemia (Hb<10g/dl) hematoma | <6 hours | 6 to 24 hours | days pulmonary embolism Reason: thrombophlebitis born there eclampsia baby’s condition other: ______mother’s condition none other: ______Infant’s problem(s): Postpartum depression: (CHOOSE ONLY ONE) jaundice beyond normal physiologic level | none | moderate | severe sepsis/infection Y N Maternal death: respiratory distress Underlying cause: ______failure to thrive (PROVIDE DETAILS ABOUT DEATH AT END OF FORM) seizures other: ______Number of postpartum visits with: days in neonatal intensive care unit Midwives Readmitted31: FP/OB/medical specialist for maternal consult Number of days after birth FP/Pediatrician for newborn/infant consult Reason readmitted: ______Naturopath/herbalist/homeopath Readmission length of stay in days Chiropractor (IF LESS THAN 1 DAY, PUT 1) estimated postpartum visits with other caregivers Y N Newborn died in first 6 weeks Specify: ______Death occurred days after birth week of final midwife postnatal visit/contact Underlying cause of death: (CHOOSE ONLY ONE) | birth defects Breastfeeding: | prematurity number of weeks breastfed in first 6 weeks | other: ______number of weeks before any supplement PROVIDE DETAILS ABOUT DEATH AT END OF FORM ( ) (IF >6 WEEKS, PUT 7) Y N Circumcision in first 6 weeks Postpartum Infant’s and mother’s health at 6 weeks— Y N Mother in hospital in first 6 weeks Infant: (CHOOSE ONLY ONE) Mother admitted from home or birth center in: | good, no problems | residual problems (CHOOSE ONLY ONE) Mother: (CHOOSE ONLY ONE) | <6 hours | 6 to 24 hours | days | good, no problems | residual problems Initial hospital stay31: (CHOOSE ONLY ONE) Form completion: | <6 hours | 6 to 24 hours | days form filled out by (INITIALS) 31 Readmitted : date majority of form filled (MM/DD/YY) Length of stay days Other relevant details? (PLEASE PROVIDE BELOW) Reason readmitted: ______Mother’s health in first 6 weeks— Postpartum infections: yeast delayed perineal healing/infection breast urinary tract uterine febrile episode (>100.4 AFTER FIRST 24 HOURS) other: ______none