Documentation: Prenatal #2 Appointment date * MM DD YYYY Appointment time * Hour Minute Second AM PM Client name * First Name Last Name Appointment location * client's home provider's office audio/video telehealth - client home audio/video telehealth - client other audio telehealth - client home audio telehealth - client other community location or shared space other Estimated delivery date * MM DD YYYY Labor support people * Risk level * low moderate high Delivery location * Delivery address * Address 1 Address 2 City State/Province Zip/Postal Code Country Delivering provider name * Delivering provider type * OBGYN CNM CPM DEM other none How do you envision your onset of labor? * scheduled spontaneous How do you envision your delivery type? * vaginal cesarean What is your plan for medication? * completely unmedicated partially medicated medicated How do you usually deal with bodily discomfort at home? * What type of coaching style are you receptive to? * What pain medications are you comfortable with? * nitrous oxide sterile water injections IV - fluids IV - NSAIDs IV - narcotics epidural Notes Which non-clinical comfort measures are you comfortable with? * aromatherapy hot compress cold compress shower vibrating massager manual massage counterpressure distraction TENS unit hypnosis/guided imagery Notes If available, how do you plan on utilizing the tub? * occasional tub usage labor in the tub deliver in the tub no tub In the event of an induction, which methods would you be okay with? * misoprostol (cytotec) dinoprostone (cervidil) foley pump (balloon) artificial oxytocin (pitocin) natural oxytocin castor oil (only under medical supervision) other Notes How would you like your and your baby's vitals to be monitored? * continuous fetal monitoring intermittent fetal monitoring handheld/mobile monitoring no monitoring When would you like to receive cervical exams? * no cervical exams when I request them when the provider suggests them on a frequent basis Describe the overall vibe you would like for the ambience of the labor room. * What tools would you like to utilize to set the ambience in the room? * electric candles dimmed room lighting string lights bluetooth speaker essential oils favorite pillows or comfort items printout of photos printout of affirmations other Do you want photos and/or videos of your birthing experience? * photos of labor videos of labor photos of pushing videos of pushing photos of postpartum videos of postpartum none Are you comfortable with male providers? * yes no Are you comfortable with residents? * yes no In extreme circumstances, are you comfortable with the presence of additional medical personnel beyond the members of your original, intended team? * yes no What are your preferences for vaginal birth? * coached pushing upright pushing perineal support guided breathing self-guided/unassisted pushing mirror Notes What are your preferences in the event of a cesarean birth? * narrated steps headphones neck/head massage clear drapes bacterial swab guided breathing Notes What are your preferences for immediate postpartum? * immediate skin-to-skin delayed cord clamping preservation of placenta assistance with latching delayed bath What would you like baby to receive at birth? * erythromycin vitamin K hepatitis B glucose test (only if necessary) hemoglobin test (only if necessary) What is your plan for your cord blood? * donate private bank discard What kind of milk is your baby allowed to have? * mother's breastmilk donor breastmilk powdered formula goat milk other Notes At what point are visitors allowed in the hospital? * immediately after 6 hours after 12 hours next day never Who is invited to visit you in the hospital? Do you have any fears, phobias or trauma that may affect your childbirth experience that you would like to share with me? * Do you have any personal, cultural or religious beliefs that may affect your ability to accept care? * General concerns * Recommendations * Resources * Appointment end * Hour Minute Second AM PM Signed (doula provider) * Are you being monitored for (developing) any conditions? * gestational diabetes gestational hypertension preeclampsia preterm delivery placental condition blood condition intrauterine growth restriction low amniotic fluid insufficient cervix other none Thank you!
