TLC Doula Service

  • Birth Preferences Worksheet

    Filling out this form will help me understand how I can best serve you and will help in writing a birth plan.

  • Full Name*
  • Procedures and Interventions

    How much would each of the following procedures or interventions upset you?

  • Stripping your membranes*
  • Inducing labor*
  • Artificial rupture of membraness*
  • Pitocin augmentation*
  • Wearing a hospital gown*
  • Routine IV*
  • Not being allowed to eat and/or drink during labor*
  • Narcotic pain relief*
    (IV pain meds)
  • Epidural*
  • Urinary catheter*
  • Continuous external fetal monitoring*
  • Internal monitoring*
  • Pushing on your back*
  • Coached pushing*
  • Episiotomy*
  • Perineal tearing*
  • Instrument assisted delivery*
    (vacuum extraction or forceps delivery)
  • C-section*
  • If you had to have a c-section, how much would it bother you not to have your doula present?*
  • Early cord clamping*
    (Before cord stops pulsating)
  • Deep suctioning of baby's airways*
  • Erythromycin in baby's eyes*
  • Vitamin K injection for baby*
  • Baby going to the nursery*
  • What elements of the birth are most important to you?

  • 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*
  • Establishing breastfeeding right away*
  • Being fully informed/giving informed consent before procedures are performed*
  • Avoiding anxiety*
  • Utilizing your doula

    Please tell me how you think I will be able to help you most during labor. You can always change your mind during labor.

  • 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 pictures during labor and/or birth*
    Disclosure: I am not a professional photographer.
  • Videotape during birth*
    Disclosure: I am not a professional photographer.
  • Other:
  • Relaxation techniques

    Which of the following, if any, have you found to be useful for relaxation in your daily life?

  • Aromatherapy*
  • Meditation or visualization*
  • Yoga*
  • Prayer*
  • Massage/touch*
  • Music*
  • Exercise*
  • Water: bath, shower, hot tub*
  • Other:
  • Security Code*