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Birth Information Questionaire
How much would each othe following procedures UPSET you? We will discuss each in-depth at our first meeting.
Name
First Name
Last Name
Estimated Due Date
MM
DD
YYYY
Stripping your membranes(without your permission)
Not at all
A little
I dont know
A Lot
Extemely
Induced Labor
Not at all
A little
I dont know
A lot
Extremely
Pitocin Augmentation
Not at all
A little
I dont know
A lot
Extremely
Artificial rupture of membranes
Not at all
A littl
I don't know
A lot
Extemely
Wearing a hospital gown
Not at all
A little
I dont know
A lot
Extremely
Routine IV during labor and birth
Not at all
A little
I dont know
A lot
Extremely
Not being allowed to eat/drink during labor
Not at all
A little
I dont know
A lot
Extremely
Narcotic pain relief
Not at all
A little
I dont know
A lot
Extremely
Epidural
Not at all
A little
I dont now
A lot
Extremely
Urinary Catheter
Not at all
A little
I dont know
A lot
Extremely
Continuous external fetal monitoring
Not at all
A little
I dont know
A lot
Extremely
Internal fetal scalp monitoring
Not at all
A little
I dont know
A lot
Extremely
Internal contraction Monitoring
Not at all
A little
I dont know
A lot
Extremely
Breath holding(purple) pushing
Not at all
A little
I dont know
A lot
Extremely
Pushing in the supine position(on your back)
Not at all
A little
I dont know
A lot
Extremely
Perineal stretching(hands in vs hands off)
Not at all
A little
I dont know
A lot
Extremely
Episiotomy
Not at all
A little
I dont know
A lot
Extremely
Vacuum extraction or forceps delivery
Not at all
A little
I dont know
A lot
Extremely
Surgical Birth (Cesarean)
Not a all
A little
I dont know
A lot
Extremely
Surgical Birth (Cesarean) WITHOUT your Doula
Not at all
A little
I dont know
A lot
Extremely
Early cord clamping (before cord stops pulsating)
Not at all
A little
I dont know
A lot
Extremely
Cord traction
Not at all
A little
I dont know
A lot
Extremely
Deep suctioning of baby's airways
Not at all
A little
I dont know
A lot
Extremely
Erythromicin in baby's eyes
Not at all
A little
I dont know
A lot
Extremely
Placenta being sent to pathology
Not at all
A little
I dont know
A lot
Extremely
Baby being bathed
Not at all
A little
I dont know
A lot
Extremely
Hepatitis B injection
Not at all
A little
I dont know
A lot
Extremely
All though it is impossible to know in advance what you may want from me, please select the things you would like me to do. You can always change your mind during labor.
Help with breathing and relaxation
Yes
No
I dont know
Massage/soothing touch
Yes
No
I dont know
Ideas for comfort and progress
Yes
No
I dont know
Help communicating with medical staff
Yes
No
I dont know
Support for your goals
Yes
No
I dont know
Remind you of your birth plan
Yes
No
I dont know
Help communicating with your family
Yes
No
I dont know
Take birth pictures
Yes
No
I dont know
Take video of birth
Yes
No
I dont know
Which of the follow, if any, have you found to be useful for relaxation in your day to day life?
Aromatherapy
Meditation or visualization
Yoga
Prayer
Massage
Music
Exercise
Water: Bath, shower, or hot tub
What elements of the birth experience are most important to you?
Feeling in control of my labor
Feeling clear headed and alert during labor
Having my partner being actively involved
Labor starting naturally
Avoiding medical interventions
Availability of medical interventions, if needed
Feeling minimal pain
Being active and mobile
Bonding with my baby immediately after birth
Seeing or touching my baby's head as it crowns
Letting my instincts guide me
Thank you!
