To Be Held Doula Services
Birth Information Questionnaire
Blank Template
1. How do you feel about this?
Select how you feel about each possible intervention or situation.
| Question | Yes | Maybe | No |
|---|---|---|---|
| Stripping or sweeping your membranes | |||
| Induced labor | |||
| Pitocin augmentation | |||
| Artificial rupture of membranes | |||
| Wearing a hospital gown | |||
| Routine IV during labor and birth | |||
| Not being allowed to eat and/or drink during labor | |||
| Narcotic pain relief | |||
| Epidural | |||
| Urinary catheter | |||
| Continuous external fetal monitoring | |||
| Internal contraction monitoring (not a choice) | |||
| Internal fetal scalp monitoring (not a choice) | |||
| Breath holding (purple) pushing | |||
| Pushing in the supine position (on your back) | |||
| Perineal stretching (hands in vs. hands off) | |||
| Episiotomy | |||
| Perineal tear (this is not a procedure) | |||
| Vacuum extractor or forceps delivery | |||
| Surgical birth (Cesarean) WITHOUT your doula | |||
| Early cord clamping (before cord stops pulsating) | |||
| Deep suctioning of baby's airways | |||
| Erythromycin in baby's eyes | |||
| Vitamin K injection | |||
| Placenta being injected with Formalin |
2. How can I help you most?
Tell me how you think you'll want my support during labor.
| Question | 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 | ||||
| Take birth pictures (photos of baby emerging) | ||||
| Videotape the birth (video of baby emerging) |
Other
3. What helps you relax?
Which of these have you found useful in daily life?
| Question | doesn't help | helps a little | helps a lot | helps most |
|---|---|---|---|---|
| Aromatherapy | ||||
| Meditation or visualization | ||||
| Yoga | ||||
| Prayer | ||||
| Massage | ||||
| Music | ||||
| Exercise | ||||
| Water: bath, shower or hot tub |
Other
4. What's most important to you?
Share what elements of the birth experience matter most.
| Question | least important | not sure | most important |
|---|---|---|---|
| Feeling in control of my labor | |||
| Feeling clear-headed and alert during labor | |||
| Having my partner be actively involved | |||
| Labor starting naturally | |||
| Avoiding medical interventions | |||
| Availability of medical intervention, 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 |
Other