Client Code:CDP716

CDP Data Collection Form

EDD: 12/15/2021

First Pregnancy?
  • No

Where did the client give birth? Albany hospital

Provider: Dr. Hovey

Primary Insurance: IHN

Priority Medicaid Populations (check all that apply):
  • Medically high risk
  • Under 21 yrs. of age
  • Homeless
  • Limited/No family support

Date of Referral: 10/22/2021

Doula: Heidi Donahue

Meet and Greet Date: 11/03/2021

Method: phone

Date of 1st Prenatal: 11/12/2021

1st Prenatal Attended By: Heidi Donahue

Location of 1st Prenatal: phone

Time: 1 hour

Date of 2nd Prenatal: 11/24/2021

2nd Prenatal Attended By: Heidi Donahue

Location of 2nd Prenatal: Clients mothers home

Time: 1.5 hours

Notes:

Talked a lot about her previous birth trauma and the removal of her daughter after she was born. We talked about her fears of this baby being taken away as well, and her losing all of her baby items when a friend stole them to be vindictive and then she had to leave that friends home, and is now staying in her moms trailer for now. we talked through her birth plan, and about the things that she feels would be triggering to her. we talked about breastfeeding, postpartum support plans, etc.

Total Prenatal Hours With Client: 4

Date of Doula Arrival: 12/10/2021

Time of Doula Arrival: 11:00

Name of hospital staff adding your arrival time to the chart notes: Amy RN

Birth Attended By: Dr. Hovey

Date of Doula Departure: 12/10/2021

Time of Doula Departure: 16:15

Name of hospital staff adding your arrival time to chart notes: Amy RN

Client birthed? Yes

Total Hours With Client: 5.25

Date of 1st Postpartum: 12/29/2021

1st Postpartum Attended By: Heidi Donahue

Location of 1st Postpartum: Zoom call

Time: 1.5

Notes:

talked about how she is feeling physically and emotionally, ecspeciallt with the inviolvement of DHS which is triggering to her and her previous birth trauma. talked about breastfeeding and formula feeding of baby. she is complaining of physical pain but drs say to take Tylenol and she feels she needs more, but they are unwilling to help. I asked her again about healthy families and a referral to them and she declined. She declined the postpartum mood survey as well. She wasn't wanting to talk about birth control either, she said she just doesn't like any forms of them.

Total Postpartum Hours With Client: 3

# of telehealth/in person visits during course of care: 3

# of text messages during course of care: 200

Date Created: December 30, 2021


Birth Summary

Summary:

Birth reflection CDP716

Evie went into labor and headed to the hospital and I was communicating with her by text throughout her early labor and let her know to call me when she was in active labor (we talked about what that would look like) and she let me know she was getting an epidural and to head to the hospital to meet her. I arrived after her epidural was done, at 11:00 and she wasn’t feeling great. Her epidural wasn’t taking away all of the pain so she was struggling with nausea and anxiety. Her boyfriend and mother were there in the room, but as soon as I got there they both left for a bit to go outside. She got her some more nausea medication, and I got her some peppermint to sniff and some cold drinks to sip on. I gave her hand massages with lavender infused body oil. We got her some of her favorite music and started playing that for her as well. I kept her distracted by talking about her daughter and the new baby and just general talking about herself and that seemed to help her. She started feeling a lot of pressure in her bottom and she asked to be checked and she was fully dilated so they set her up to push. She began pushing at 12;45, and baby was born at 1:15.
Everything went well and she didn’t need any stitches or repairs. Dr. Though that baby might have had meconium so they had to take baby over to the warmer for them to check on her lungs, but she got to come back to Evie after a few minutes as she was doing really well. Evie/s boyfriend left to go downstairs shortly after baby Freya was born, so I stayed with Evie and helped her get baby latched for a first feed and took pictures of mom and baby together. It took quote awhile for Evie to regain feeling in her legs from the epidural and she was feeling really sick and nauseous with a bad headache so I held the baby for awhile at her request while she sat with her head in her lap. I set the baby in the bassinet after a few minutes and fanned Evie as she was feeling extremely hot, and then got her the peppermint oil again and continued to push her to drink and take a few bites of food. She was able to get ibuprofen and then about 45 minutes later she started feeling a bit better and was ready to hold baby freya again and try to nurse again. We got Evie up into the shower and she sat in there for quite awhile while I packed up all their things and got everything ready for her to move to the new room. I left at 4:15, and mom and baby were getting settled into the Postpartum room and Grandma was there with her to stay the night,

Date Created: December 30, 2021


Client Confidentiality Release Form

Doula's name: Heidi Donahue

Signature:

Date signed: 11/24/2021

Date of birth: 07/10/1998


CDP Letter of Agreement

Client signature:

Date signed: 11/24/2021


Required Documents Checklist

Confidentiality Release Form:
  • Completed

CDP Data Collection Form:
  • Completed

Birth Summary:
  • Completed

Entry date: March 31, 2022