Birth WishesHow much would each of the following upset you? It is very important for us to get to know you and your family. Name * First Name Last Name Partner's Name (if applicable) First Name Last Name Primary Doula's Name First Name Last Name Stripping your membranes not at all a little I don't know a lot extremely Induced labour not at all a little I don't know a lot extremely Pitocin augmentation not at all a little I don't know a lot extremely Artificial rupture of membranes not at all a little I don't know a lot extremely Wearing a hospital gown not at all a little I don't know a lot extremely Routine IV during labour and birth not at all a little I don't know a lot extremely Not being allowed to eat and/or drink during labour not at all a little I don't know a lot extremely Narcotic pain relief not at all a little I don't know a lot extremely Epidural not at all a little I don't know a lot extremely Urinary catheter not at all a little I don't know a lot extremely Continuous external fetal monitoring not at all a little I don't know a lot extremely Internal fetal scalp monitoring (not a choice) not at all a little I don't know a lot extremely Internal contraction monitoring (not a choice) not at all a little I don't know a lot extremely Pushing in the supine position (on your back) not at all a little I don't know a lot extremely Breath holding (purple) pushing not at all a little I don't know a lot extremely Nurses counting (cheerleading) during pushing not at all a little I don't know a lot extremely Episiotomy not at all a little I don't know a lot extremely Perineal tear (this is not a procedure) not at all a little I don't know a lot extremely Vacuum extractor or forceps during delivery not at all a little I don't know a lot extremely Surgical birth (Cesarean) not at all a little I don't know a lot extremely Surgical birth (Cesarean) WITHOUT your doula not at all a little I don't know a lot extremely Early cord clamping (before cord stops pulsating) not at all a little I don't know a lot extremely Routine deep suctioning of baby's airways not at all a little I don't know a lot extremely Erythromycin in baby's eyes not at all a little I don't know a lot extremely Vitamin K injection not at all a little I don't know a lot extremely Healthy baby going to nursery not at all a little I don't know a lot extremely Although it's impossible to know in advance what you will need from me during labour please tell me how you think I will be able to help you the most. You can always change your mind during labour. Help with breathing and relaxation don't need need a little not sure need a lot need most Massage/soothing touch don't need need a little unsure need a lot need most Ideas for comfort and progress don't need need a little unsure need a lot need most Support for your goals don't need need a little need a lot need most Remind you of your goals don't need need a little need a lot need most Help communicating with your family don't need need a little need a lot need most Take birth pictures (photos of baby emerging) don't need need a little need a lot need most Videotape the birth (video of baby emerging) don't need need a little need a lot need most Which of the following, if any, have you found useful for relaxation in your day to day life? Aromatherapy doesn't help helps a little helps a lot helps most Meditation or visualization doesn't help helps a little helps a lot helps most Yoga 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 or hot tub doesn't help helps a little helps a lot helps most Other What elements of the birth experience are most important to you? Feeling in control of my labour least important not sure most important Feeling clear-headed and alert during labour least important not sure most important Having my partner be actively involved least important not sure most important Labour starting naturally least important not sure most important Avoiding medical interventions least important not sure most important Availability of medical intervention, 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 babies head when it crowns least important not sure most important Letting my instincts guide me least important not sure most important Other Thank you!
