The following is a sampling of items for the mother and father to respond to
on the Birth Information Questionnaire. I ask the parents to fill this form out
so I have a clear idea of the kind of labor and birth they are hoping to have,
and which interventions are totally fine for them and which, if any, they
wish to avoid.
For the record - I will support whatever decision you make for
your labor and birth. I am here to be your advocate and encourage you!
On the actual form, there are places for the couple to circle
"Really Upset" "A Little Upset" "I don't know" "Semi-Okay" or "Totally Fine"
in response to these items:
Stripping your membranes (w/o your permission)..... | |||||
Stripping your membranes (w/ your permission): | |||||
Induced Labor: | |||||
Pitocin augmentation: | |||||
Wearing a hospital gown: | |||||
Routine IV during labor and birth: | |||||
Not being allowed to eat/drink during labor: | |||||
Epidural: | |||||
Narcotic pain relief: | |||||
Continuous external fetal monitoring: | |||||
Artificial rupture of membranes: | |||||
Breath holding pushing: | |||||
Pushing in the supine position (on your back): | |||||
Nurses counting (cheerleading) during pushing: | |||||
Episiotomy: | |||||
Local Anesthetic: | |||||
Vacuum extractor or forceps delivery: | |||||
Perineal tear (this is not a procedure): | |||||
Surgical Birth (Cesarean): | |||||
Surgical Birth (Cesarean) Without your doula: | |||||
Early Cord Clamping (before cord stops pulsating): | |||||
Erythromycin in baby’s eyes: | |||||
Vitamin K injection: | |||||
Routine deep suctioning of baby’s airways: |
_______________End of Partner Section__________________
The rest should be filled out by the mother.
Although its impossible to know in advance what you will need from me during labor, please tell me how you think I will be able to help you most. You can change your mind during labor.
Here, on the actual form, Mothers can choose the following answers: "Don't Need" "Need a little" "Need a lot" "Need Most" Help with breathing and relaxation: | ||||
Massage/soothing touch: | ||||
Ideas for comfort and progress: | ||||
Help communicating with medical staff: | ||||
Support for your goals: | ||||
Remind you of your birth plan: | ||||
Help communicating with your family: | ||||
Offer Aromatherapy: | ||||
Answers for the Photography Questions are: "Don't Need" "May Need" "Want" Photography of the labor: | ||||
Photography of the birth: Photography of baby and bonding: | ||||
Other: |
Which of the following, if any, have you found to be useful for relaxation in your day to day life:
Aromatherapy………………….. | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Meditation……………………... | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Visualization…………………… | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Prayer…………………………... | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Massage………………………... | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Music………………………….. | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Exercise……………………….. | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Water: Bath, shower, hot tub…. | Doesn’t help | Helps a little | Helps a lot | Helps most | |
Other_____________________ | Doesn’t help | Helps a little | Helps a lot | Helps most | |
What elements of the birth experience are most important to you?
Feeling in control of my labor……………… | Least important | Not sure | Most important |
Feeling clear-headed and alert during labor… | Least important | Not sure | Most important |
Having my husband be actively involved…….. | Least important | Not sure | Most important |
Labor starting naturally…………………… | Least important | Not sure | Most important |
Avoiding medical interventions…………....... | Least important | Not sure | Most important |
Availability of medical interventions, if needed | Least important | Not sure | Most important |
Feeling minimal pain……………………........ | Least important | Not sure | Most important |
Being active and mobile……………………... | Least important | Not sure | Most important |
Bonding with my baby immediately after birth | Least important | Not sure | Most important |
Seeing or touching my baby’s head as it crowns | Least important | Not sure | Most important |
Letting my instincts guide me……………….. | Least important | Not sure | Most important |
______________________________________ | Least important | Not sure | Most important |
______________________________________ | Least important | Not sure | Most important |
______________________________________ | Least important | Not sure | Most important |
