HOME WATER HOSPITAL IF Hospital; MET Or LEAMINGTON

CHILDBIRTH INFORMATION RECORD

DATE:______EDD:______Confirmed by U/S: Y N

HOME WATER HOSPITAL IF Hospital; MET or LEAMINGTON

MOTHERS NAME:______AGE_____ PARTNER:______

CHILDREN & AGES:______

ADDRESS: ______

PHONE #’s of BOTH PARTNERS:______

EMAILS of BOTH PARTNERS:______

PETS______PLAN FOR CHILDCARE/PET CARE______

GRAND PARENTS: ______Will they be involved Y N

HEALTH CARE PROVIDERS

PRIMARY:______

FAMILY CARE:______

CHILDBIRTH EDUCATION:______

BREASTFEEDING: Y N BF BEFORE? Y N DATE OF BREASTFEEDING CARE:______

ANY MEDICAL CONDITIONS RELATED TO PREGNANCY ie SMOKER, ALCOHOL, PIH, ______

______

Have you ever had a cervical biopsy? Yes No

RH + RH- HIV GBS + GBS- HEPATITIS A B C

PREVIOUS LABOUR:______

HISTORY OF PPD : YES NO IN Mother or Sisters? YES NO

HISTORY OF ABUSE?______

SPECIFIC FEARS ABOUT BIRTH? :______

ANY CULTURAL, RELIGIOUS OR SOCIAL BIRTH CUSTOMS?______

PRENATAL/POSTPARTUM CHECKLIST

Prenatal 1

DATE: ______LOCATION: ______DOULA: ______

□ Contract reviewed and signed

□ Client Information Record

□ Assign Birth Plan for prenatal #2 meeting

□ Prenatal Education - If not taking prenatal classes leave list of reading/watching

□ Give client binder and explain to bring to visits/hospital

□ Deposit of $150 collected

Prenatal 2

DATE: ______LOCATION: ______DOULA: ______

□ Go over their birth plan

□ Signs of labour

□ When to call and what to expect

□ Give out on-call phone numbers

□ A walk through of the home – current resources available.

□ Remainder of deposit $850 if Midwife or $500 if OB. If classes are taken, deduct $50

□ Resources given (web, book, video etc) ______

Postpartum

DATE: ______LOCATION: ______DOULA: ______

□ Breastfeeding

□ Sleep

□ Postpartum recovery

□ Emotional wellbeing

□ Feelings about the birth

□ Obtain client binder and lent resources

□ Have client fill out evaluation/give feedback

CONTRACT

Prenatal Services:

Interview: Approx ½ hr.

To see if we're a good fit, we can talk over the phone or meet in person. This is a good opportunity to ask any questions about doula services and to see if we would work well together. Should we choose to work together, your due date will be reserved and we will be on call for you 24 hours a day for questions, concerns and for your labour.

Two Prenatal Visits: Approx: 1 - 1.5 hr(s) each

During your pregnancy doula services includes two prenatal visits where we will explore your hopes and preferences for labour and postpartum, address any fears or concerns regarding your pregnancy labour or parenting and see how you would best be supported during childbirth.

Phone Support:

In addition to our meetings, we are also available by phone for questions and concerns at any time. You are encouraged to call whenever something changes that may indicate the onset of labour. Consistent communication allows for the best support possible leading up to your labour. We will be on-call continuously two weeks prior to and two weeks after your due date for 24 hour support.

Community Referrals:

Being familiar with a number a resources for pregnancy, childbirth and parenting in Windsor, we are able to provide references for you if desired. You may also be referred to a practitioner should your questions or needs be out of our scope of practice as doulas.

Labour & Delivery:

When you need our support in labour we will come to your home, or meet you at the hospital. Typically, you receive support during labour before the transition to hospital or the arrival of your midwife/Dr. During this time, we will help to interpret the progress of labour, provide comfort measures, offer alternative pain coping practices, and prepare food or offer support and reassurance to partners.

A doula works in a team with your partner. In our prenatal visits, our discussions and activities build confidence in partners as they find their comfort level as labour support. During your labour, a doula helps partners to become involved to the degree they are comfortable, and will continue to support the birthing mom if her partner needs a break to sleep or eat.

Postpartum:

After your baby is born we will stay with you for one-three hours. In this time, continuing to advocate for you and hold space for your new family. We will also tidy your home or birth area and provide breastfeeding support.

Postnatal Visits: 2 x Approx: 1 hr each

We meet twice in the weeks following your baby's birth. It can be helpful to meet once in your baby's first week, and once in the second or third week of postpartum. During these visits breastfeeding and baby care support is provided. We can also explore how you are feeling about your transition into parenthood and the challenges you have met so far. We can also discuss your experience of birth and answer any questions you may have.

What is a labour doula?

A labour doula’s scope of practice is to accompany families in labour to help them have a more satisfying birth experience. She provides emotional support, physical comfort and, as needed, information regarding clinical procedures. Information to ensure that you have the information needed to make informed decisions as they arise during labour.

A labour doula can provide reassurance and perspective to you and your partner, make suggestions for labour progress, and help with relaxation, massage, positioning and other comfort techniques. Doula’s are independent and self-employed, meaning your doula works for you, not your caregiver or hospital.

What a labour doula doesn’t do?

·  Any clinical/medical tasks such as taking blood pressure, fetal heart checks etc.

·  Make decisions for you. We will help you get the information you need to make an informed choice. We will also remind you if there is a departure from your birth plan.

·  Speak to the medical staff instead of you regarding matters where decisions need to be made. Instead we will discuss the risks, benefits and alternatives, but you and your partner will address the medical staff.

When you are in labour

Please follow your Dr./Midwives requests and then call your labour doula if you think you are in labour, even if you do not need support. We can answer questions and make suggestions over the phone. At this point, together we will decide if you need immediate assistance or if we should wait for further change. Approximately 1.5 hours are needed to get to you from the time you ask your doula to come. We will also decide where to meet and except for in extraordinary circumstances will we not be available to you. In this case a back up doula is available.

Shared Care Model

The Family Wellness Centre offers our clients a comprehensive shared model of support. Shared care support means thatyou willmeet up tofourhighly skilled, experienced, and like-minded doulas duringyour prenatal period. Two doulas are always available on an on-call basis, but likely only one of our doulas will attend your birth. This depends who is on call when you go into labour.

Clients will also have the opportunity to meet and socialize with all of our doulas during prenatal visits, education classes or alternative services that we offer. Services such as maternal reflexology, placenta encapsulation, birth and parenthood retail products and registered massage therapy services are additional resources we are able to provide.

This model of care offers clients reassurance that the doula attending is someone they have had the opportunity to develop a prenatal relationship with,eliminatingthe need for aback-up doula with whom youmay have notmet and had the opportunity to share your birth preferences with.

Our doula team has a combined 15+ years of holistic and medical experience. We bring this knowledge into your prenatal sessions, your birth and into postpartum recovery if you desire. We work as a team, using a shared care model because we believe strongly in comprehensive and consistent care. We have developed a program that allows us to really build a relationship with each of our clients, pulling from many skill sets.

C-Sections

There are two ways c-section support can come about.

1)  Unplanned – where the doula attended your labour, and c-section delivery – in this scenario, the full fee is still charged.

2)  Planned – where something potentially shifted medically in your pregnancy, and a c-section is planned. In this scenario you can either choose to have us support you, or decline our care. If you choose our support, we will refund you $525 for an OBGYN led birth and $275 for a midwifery led birth. If you choose not to have our support, then you will be refunded half of the total amount of the services

Fees

The fee for the services described here is $600 for a birth with a midwife and $1000 for a birth with an OB-GYN.

$150 non-refundable retainer fee, due on your first prenatal visit, and the remainder is due at your final prenatal visit

If your baby is born before this time, your payment is due within ten days after the birth. If an induction or c-section is scheduled, payment is due before the scheduled date.

Discounts

As a collective we gladly offer a $50 discount on doula services if you decide to participate in the Prenatal Wisdom classes with The Family Wellness Centre. www.thefamilywellnesscentre.com

Please note it is against company policy to attend the birth of a client who has not made their final financial commitments as requested above.

I/We have read this contract describing The Family Wellness Centre services and agree that it reflects the discussions we have had pertaining to doula services.

I/We also understand that The Family Wellness Centre doula’s are in no way responsible for any medical/clinical outcome of our birth.

Client Name(s) ______

Client(s) Signature(s) ______

Doula(s) Name & Signature ______

Date ______

Payment 1______Payment 2______

C-Sections

There are two ways c-section support can come about.

1)  Unplanned – where the doula attended your labour, and c-section delivery – in this scenario, the full fee is still charged.

2)  Planned – where something potentially shifted medically in your pregnancy, and a c-section is planned. In this scenario you can either choose to have us support you, or decline our care. If you choose our support, we will refund you $525 for an OBGYN led birth and $275 for a midwifery led birth. If you choose not to have our support, then you will be refunded half of the total amount of the services

Fees

The fee for the services described here is $600 for a birth with a midwife and $1000 for a birth with an OB-GYN.

$150 non-refundable retainer fee, due on your first prenatal visit, and the remainder is due at your final prenatal visit

If your baby is born before this time, your payment is due within ten days after the birth. If an induction or c-section is scheduled, payment is due before the scheduled date.

Discounts

As a collective we gladly offer a $50 discount on doula services if you decide to participate in the Prenatal Wisdom classes with The Family Wellness Centre. www.thefamilywellnesscentre.com

Please note it is against company policy to attend the birth of a client who has not made their final financial commitments as requested above.

I/We have read this contract describing The Family Wellness Centre services and agree that it reflects the discussions we have had pertaining to doula services.

I/We also understand that The Family Wellness Centre doula’s are in no way responsible for any medical/clinical outcome of our birth.

Client Name(s) ______

Client(s) Signature(s) ______

Doula(s) Name & Signature ______

Date ______

Payment 1______Payment 2______

BIRTH OPTION PREFERENCES

SUMMARY OF LABOUR/BIRTH

Client Information

Name Partner’s Name

Due Date Initial Birth Plan □ Unknown □ Natural □ Medicated

Labour & Birth

Birth Date Location of delivery □ Hospital

□ Home

Labour length Doctor/Midwife

Interventions Medications Method of Birth

□ Prostaglandin induction □ Stadol □ Vaginal

□ Cytotec/Cervadil induction □ Nubain □ Forceps

□ Pitocin induction □ Demerol □ Vacuum

□ Pitocin augmentation □ Sterile Water Injections □ VBAC

□ AROM □ Epidural before 5cm □ Repeat Cesarean

□ Intermittent EFM □ Epidural after 5cm □ Unexpected Cesarean

□ Continuous EFM □ Spinal □ Planned Cesarean

□ Other □ General Anesthesia

Newborn

Name Weight Sex □ M □ F

Outcome

□ Normal □ Premature □ Postmature □ Stillbirth □ Defect

Postpartum

□ Rooming in □ Nursery □ NICU □ Breastfeeding

Notes

FOLLOW-UP SURVEY

Please take a few minutes to complete the following survey. Your remarks will help us provide better service for all new mothers and their families.

1.  What was the name of your doula?

2.  Did you attend prenatal classes □ Yes □ No

3.  Who other than your doula was there to support you?

□ Partner or spouse □ Parent □ Friend □ Other

4.  Please check all services that were provided by your doula during labour and birth.

□ Massage □ Position changes □Cold/Hot packs □Shower/Bath

□ Acupressure □ Counterpressure □ Water/Juice □ Eased Fears

□ Took photos □Breathing techniques □ Followed wishes □ Verbal encouragement

□ Labour ball □ Double hip squeeze □ Knee press □ Answered questions

□ Eye Contact □ Discussed options □ Reinforced ritual □ Continuous presence

□ Helped partner □ Other

5.  Which services helped you the most?

6.  Any services you did not like? Please specify.

7.  How did your doula interact with members of your birth team (partner, physician, nurses)?

□ Very Well □ Well □ Sufficiently □ Poorly

8.  Was the time that the doula spent with you following the birth helpful? Please explain.

9.  I feel that the fee I paid for the doula service was

□ fair □ too high □ too low

10.  How did you learn about our services?

Additional Comments

RESOURCES