What is your "ideal birth"? What do you picture in your head when you imagine this special event?
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Have you discussed your intentions with your health care provider? Are you comfortable or uncomfortable communicating with them?
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At what point in labor would your health care provider like you to call them? When would they prefer to join you?
Does your care provider know that you have chosen to hire a doula?
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Yes
No
I'm not sure
Do you and your care provider have a plan in place in case you go past your due date?
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How are you preparing for your birth?
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Do you have any fears, doubts, or concerns about your labor or birth?
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What do you think will be a source of strength for you during your labor? A source of comfort?
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What are some ways you usually manage pain?
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What kind of assistance do you think will be most helpful for you?
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How does your partner want to be involved? How would you like them to be involved?
Who would you like present during your labor?
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Parent(s)
Children
Doula
Friends
Other
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Wearing my own clothes
Fluids
Ice/Popsicles
Food
Aromatherapy
Music
Low Lighting
Walking
Shower/Tub
Rebozo
Ball/Peanut
Other
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Continuous Fetal Monitoring
Intermittent Fetal Monitoring
No IV or Heparin lock
IV
Vaginal checks done as per protocol
Limited vaginal checks (only when necessary)
Spontaneous rupture of membranes
Medications offered (epidural)
Do not offer me medications
Epidural/narcotics
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Laboring parent chooses positions
Health care provider chooses positions
I'd like my doula to take photos
I've chosen someone to take photos
Perineal massage
Episiotomy
Natural tearing preferred to episiotomy
Cord cut by partner
Cord cut by health care provider
Delayed cord clamping
Baby caught by partner with the help of health care provider
Announce the sex of the baby
Immediate chest placement
Baby cleaned before given to parent
Delay newborn procedures for one hour
Placenta delivered without pitocin
If your health care provider recommends an induction/augmentation
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No induction
Pitocin
Prosteglandin gel or suppositories (E-2: Prostin, Prepadil, Cervadil, dinoprostone)
Cytotec/Misoprostal (E-1)
Artificial rupture of membranes (breaking waters, AROM)
Foley catheter
Nipple stimulation
Other natural methods
If you have or need a scheduled C-section
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Epidural
Spinal
Partner present
Doula present
Partner to cut cord, if possible
Doula with mom during repair
Pictures + video
Dropped or clear drape
One arm free to touch baby
Breastfeeding in recovery
Are there any religious or spiritual practices you would like to incorporate into your birth? Would you like my help facilitating any of them? Would you like privacy?
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Save placenta
Placental encapsulation
Save cord blood
In-hospital lactation consultation
None
Feeding methods
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Breast/chest feeding
Formula
Expressed bottle-feeding
Not sure
What are your experiences with breast/chest feeding? Do you have any concerns about your ability to breast/chestfeed?
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Do you have any issues, concerns, or fears regarding newborn care + taking your baby home?
Should health care staff
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Leave baby in the room
Take baby to the nursery with family
Bottlefeed baby
Give pacifiers
Provide a lactation consultant
Waive eye ointment
Waive Vitamin K shot
Waive PKU test
Waive glucose test
Waive Hepatitis B test
Schedule circumcision
Other
"I'd like"
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Same day discharge (if possible)
A lactation consultant
A postpartum doula
A postnatal education class
A La Leche League contact
Information on a new parent support group
A postpartum depression screening
Do you have any fears or concerns about being a new parent?
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What does your postpartum support system look like? Who will be helping with recovery, errands, housework, meal preparation, etc?
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Do you have a pediatrician selected?
Do you have any additional concerns for me? Don't hold back!