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 pregnancy and delivery history Midwife Code1 Number of previous: pregnancies Second Midwife Code1 (OPTIONAL) miscarriages5 Third Midwife Code1 (OPTIONAL) induced abortions 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 episiotomies 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 shoulder dystocia 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 amniocentesis pre-existing hypertension6 biophysical profile 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