Summit Doula Care
What is a Doula?
Your Birth Package
This information is highly personal and is important in serving you individually and preparing fully for your birth. It is kept completely confidential. Feel free to leave anything blank or use a separate page. The information will be shared with the back-up doula, upon your approval. Please return the completed forms before our first scheduled prenatal visit.
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Name and Age of Children
Partner's Phone Number
Relationship with Partner
General Physical Health
Please describe your past and present overall health and list any chronic illnesses, allergies, medications, previous accidents, surgeries, history of substance use, etc.
Current Pregnancy Health
Please describe your physical health during this pregnancy so far, any complications or difficulties you have had, pregnancy discomforts or sleeping problems, and negative results of any pregnancy tests. Did you have any infertility or conception treatments?
General Emotional and Mental Health
Please describe your past and present overall well-being and list any history of depression, anxiety, sleep problems, or adjustment difficulties.
Current Pregnancy Mental and Emotional Health
How have you felt emotionally during this pregnancy? What are some of the ups and downs? Particular stresses? Anxieties? Unresolved worries or conflicts?
Hopes and Priorities
Mother: What is most important to you about this birth experience? Do you have any hopes or expectations about how the birth will go? How would you define a “good” birth experience?
Partner: What is most important to you about this birth experience? Do you have any hopes or expectations about how the birth will go? How would you define a “good” birth experience?
Fears and Concerns
Mother: What concerns you about the labor ahead? Do you hold any fears or self-doubts?
Partner: What concerns you about the labor ahead? Do you hold any fears or self-doubts?
Mother: How do you feel about your ability to give birth? What strengths do you already bring to your birth? What helps you to feel powerful? What strengths will you draw on from your partner?
Partner: What strengths do you see in yourself as a support person to your partner? As a future parent? What strengths do you see in her?
Mother: What are your needs regarding labor support? What feels supportive to you? Which of these are you looking toward your partner for? What ways would you like me to support you?
Partner: What role would you feel most comfortable in providing support? How do you envision us working together? What is the best way for me to offer you suggestions?
What do you feel is the best approach for you in dealing with labor pain? Can you share any experiences you have had with pain before?
What are your feelings about the use of pain medications in labor? What would you like me to do if you ask for them? Would you like to use a safe word?
How do you usually react when under pain or stress? What coping methods have you used before? What coping strategies have you learned in your birth class that you think might be most helpful?
What if Situations
If there are problems or complications, what would your priorities be? Who goes with Mom or baby if they must be separated? What are your needs in the event of the unexpected?
Tell me about birth in your family-- are there any customs or traditions you would like to incorporate?
After the Birth
How do you hope to greet your child immediately after birth? Special ceremonies or traditions? What is most important to you in the first few hours? First few days?
A history of negative life events such as the loss of loved ones, severe injuries or trauma, or experiences of abuse or neglect can greatly impact your emotional needs during labor and birth. If you desire to share any experiences with me so I can better serve you as your doula, please do so here.
Previous Pregnancy Experiences
Please list, in order, your previous pregnancy experiences that did not result in birth (include miscarriages, abortions, stillbirths, etc). Include what, if any, healing work has been done. Do you experience anxiety due to these events?
Please list, in order, a description of labor for each of your births. What was helpful and not, what were positive and negative aspects, how you were treated by staff? What would you like different this time?
Previous Breastfeeding Experiences
Describe the initiation and early days of breastfeeding. Any problems? Help received? Advice that was and was not helpful? Partner’s feelings about the experience? When did you wean and what led to that?
Previous Postpartum Experiences
Describe your physical recovery and any difficulties. Emotional adjustments? Mood disorders? Care taking of baby? Adapting to mothering or fathering roles? Couple relationship? Bonding with Baby?
Please check off any tools for labor that you do not want to consider using during your birth.
Scented massage oils/lotions
Massage/touch in the following areas:
Please share any details regarding your labor care preferences indicated above.