Client Code:CDP700

CDP Data Collection Form

EDD: 11/22/2021

First Pregnancy?
  • Yes

Where did the client give birth? corvallis birth center

Provider: Melissa Hilson

Primary Insurance: IHN

Priority Medicaid Populations (check all that apply):
  • Racially/Ethnically diverse
  • Limited/No family support

Date of Referral: 09/28/2021

Doula: Heidi Donahue

Meet and Greet Date: 10/07/2021

Method: phone

Date of 1st Prenatal: 10/20/2021

1st Prenatal Attended By: Heidi Donahue

Location of 1st Prenatal: clients home

Time: 1.5 hrs

Notes:

explained the roles of a doula. what we do/ do not do.
asked what kind of support she is looking for, what what be the most helpful for her during the labor/birth, what her postpartum plan looks like. She just moved here from Hawaii during her pregnancy to be with her partner, and so she has no family or friends here in Oregon. She feels alone as far as female support and although her partner is vert attentive and involved, would like a female presence with experience with birth to be there to coach both of them through this. She plans to have her baby at the corvallis birth center, and feels as though she is choosing the right path by doing a drug free birth but is nervous about how to manage the pain and would love help and guidance on how to deal with it during the moment. we discussed things that both I and her partner could do to help her manage the contractions and she felt very at ease after we discussed.
Lonnie (her partner) will take a week or two off of work after baby arrives but then she will be completely on her own, so the idea of having some extra female support after postpartum sounds very reassuring to her.

Date of 2nd Prenatal: 11/08/2021

2nd Prenatal Attended By: Heidi Donahue

Location of 2nd Prenatal: clients home

Time: 1.5 hrs

Notes:

talked about how she is feeling and she said overall she feels great. we talk more about her birth plan, and she was saying that she doesn't not want any of the things offered for baby other than the heel prick done. she wants lonnie to cut the card after birth and then they plan to bring a cooler to bring the placenta home for someone to come get and encapsulate for them.
she is getting a little nervous, and we talked about some of the things she could do to get ready for the birth such as spending time on the birth ball, doing some good stretching and getting plenty of rest. I gave her and lonnie some "homework" to do where they could practice some of the labor positions together and see how they feel and get a good laugh together, and to practice hip squeezes and counter pressure and see what feels good to her. we talked about when to call me during labor and when doulas typically show up. we talked a bit about breastfeeding and what she had questions about regarding breastfeeding right after birth.

Total Prenatal Hours With Client: 5

Date of Doula Arrival: 11/16/2021

Time of Doula Arrival: 16:00

Birth Attended By: Heidi Donahue

Date of Doula Departure: 11/17/2021

Time of Doula Departure: 01:30

Client birthed? Yes

Total Hours With Client: 9.5

Date of 1st Postpartum: 11/22/2021

1st Postpartum Attended By: Heidi Donahue

Location of 1st Postpartum: clients home

Time: 1.5

Notes:

spoke a lot about breastfeeding, and just giving her some basic understanding of infant feeding.
talked through her labor and birth experience. spoke with her about how her postpartum healing, and Lonnie let me know he was going to be home for another week and Kaylee was very happy about that. She doesn't have any friends/family in Oregon, and so other than lonnie and his family she doesn't have any help or support and so we talked about things she could do to keep herself from feeling too lonely and to feel like she has emotional support when lonnie is at work.

Date of 2nd Postpartum: 12/14/2021

2nd Postpartum Attended By: Heidi Donahue

Location of 2nd Postpartum: clients home

Time: 1.5

Notes:

talked a lot about breastfeeding..different techniques, is this normal type questions. and just talked through the emotions of breastfeeding a newborn and being tied to them so much.
talked about the emotions of being a new mom a lot.
asked her about family supports, if she feels like there is anything she needs help with or resources. spoke about healthy families, she declined. had her fill out the postpartum depression scale form.

Total Postpartum Hours With Client: 4

# of telehealth/in person visits during course of care: 4

# of text messages during course of care: 150

# of phone calls during course of care: 1

# of emails during course of care: 1

Date Created: December 15, 2021


Birth Summary

Summary:

Kylee called me at 2:40, letting me know they were headed to the corvallis birth center, after her being in labor all morning and contractions were now 3-4 mins apart. I arrived at the birth center at 4:00pm, and when I got into the room, she was in the bath and her boyfriend was holding her hand. her contractions were 3 mins apart, and she was breathing through them great. Kaylee said she hadn't had anything to eat or drink other than water since 10am, so I went and got her some apple juice, and filled dads water and got some ice water and washcloths for her neck and face. she continued to labor in the tub and after 2 hours we got her out to use the bathroom and labor on the toilet. she was laboring a lot harder at this point and her body was contracting almost constantly so the midwife asked her to go onto the bed on all fours to try and give her uterus a break. at this point Kaylee was dilated to about 8 cm. and was laboring harder and wanted back in the tub. her contractions stayed very close and her ability to breathe through the contractions had stopped and she was involuntarily pushing. after 2 hours she was checked again and still at 8 cm with swollen cervix. she kept laboring and I massaged her shoulder while she was in the tub using lemon essence oil, and wiped the back of her neck and her face with cold water, and poured warm water from the bath down her back and arms. she continued to labor very hard with only very short breaks between contractions. the midwife asked her to change position since she her body had been pushing for hours at this point and she wasn't having any change. we got her onto the bed on her side and she was screaming through every contraction and in between some of them also, she was having horrible back pain and screaming so her boyfriend and I took turns using counter pressure constantly for her, and then the midwife brought in the tens unit and hooked it up to her back, she also received 50 mg Benadryl at this point to help with swelling of the cervix and take the edge off for her. when I wasn't doing you her pressure, I was giving her drinks of juice, rubbing her head and massaging her arms and back. baby was in a bad position it seemed, and she had been pushing for hours involuntarily with her cervix still not completely gone. she was just contstanly screaming at this point. they called in another midwife to try and manually maneuver her cervix out of the way, or the other option they were considering was a hospital transfer to get an epidural and sleep. Kaylee was just writhing in pain, and I kept rubbing her hair and back and offering positive affirmations and telling her she was ok. the midwife was able to get her cervix opened and they set Kaylee up for 2nd stage pushing and she strongly pushed for 18 mins and baby girl Gloria-Grace was born at 12:02am on November 16th. placenta was delivered about 10 mins later. Kaylee didn't have any tearing and was doing great.
I got her some more juice, got dad water, and took photos for them. the midwives made them a fresh smoothie while I helped Kaylee get baby latched on to breastfeed, and baby girl took right to it and had been latched on actively sucking for 25 mins. midwifes were starting to cook some breakfast food for them when I left at 1:30am. mom was resting with eyes closed with baby nursing when I left.

Date Created: November 16, 2021


Invoice Form (Credentialed Doulas)

Invoice Date: 12/14/2021

Check All Services Provided:
  • Global Package: 2 Prenatal, Birth, 2 Postpartum


Required Documents Checklist

CDP Data Collection Form:
  • Completed

Birth Summary:
  • Completed

Invoice:
  • Completed

Entry date: March 31, 2022