Pregnancy and Birth History | Feed the Baby LLC

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Pregnancy and Birth History

Client's Name

Client's Age/Birth Date

Phone Number

Email Address

Client's Obstetrician or Physician, Including Practice, Address, and Phone Number

Infant's Name

Infant's Age/Birth Date

Infant's Primary Care Provider, Including Practice, Address, and Phone Number

How Many Pregnancies

How Many Births

Pregnancy Complications

Infertility

Previous Miscarriages

Premature Labor

Anemia

Infection

Pregnancy Induced Hypertension

Pre-eclampsia

Gestational Diabetes

Hyperemesis

Bleeding

Abruption

Bedrest

Any Other Pregnancy Complications

Please List All Medications, Supplements, Herbs, Tinctures, Teas, Essential Oils, or Homeopathics Used During Pregnancy

Did Breast Size Change During Pregnancy. If So, When and How Much

Infant's Gestational Age at Birth

Birth

Vaginal

Planned Cesarean

Emergency Cesarean

Unexpected Cesarean

VBAC

Premature Rupture of Membranes

Induction

Epidural

Spinal

General Anesthesia

Pitocin

Medication-Free Labor and Birth

IV Fluids

Birth Complications

Labor Longer Than 30 Hours

Pushing Stage Longer Than 2 Hours

Breech

Asynclitic

Posterior

Forceps

Vacuum

Hemorrhage

Shoulder Dystocia

Meconium

Cord Around Neck

Hand(s) Near Face (Nuchal Hand(s))

Episiotomy

GBS+

Total Length of Labor

Total Length of Pushing Stage

Infant APGAR

Did You Have Immediate Skin-to-Skin Contact

When Did Infant First Latch

Infant Neonatal Complications

Breathing Difficulties

Low Blood Sugar

Fluid Aspiration

Meconium Aspiration

Jaundice

Parent Postpartum Complications

Infections

UTI

Hemorrhage

Low Blood Pressure

High Blood Pressure

Pain

List Any Other Parent or Infant Complications

Medications Used During Birth and Postpartum Including Antibiotics

Describe Your Birth Experience and/or Provide any Missing Details

Did Infant Spend Any Time in NICU/How many Days

How Long After Birth Were You Discharged

Infant's Birth-Weight

Infant's Lowest Weight

All Other Available Weights and Dates

How Many Previous Surgical Births Have You Had

How Many Previous Vaginal Births Have You Had

Describe Previous Pregnancies and Births Including Complications

If you are human, leave this field blank.

Located in Central lower Michigan

For more information, call (517) 285-7819 or email feedthebabyllc@protonmail.com
Laura Spitzfaden

International Board Certified Lactation Consultant providing in-home visits for breastfeeding support in Lansing, Michigan and surrounding communities

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None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice.

Original artwork Copyright ⓒ 2012 Cameron Spitzfaden

None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice.

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