Postpartum Doula Care

Main reason for desiring postpartum Doula care? ________________________________________________________________________________

Will  Dad and or a family member or friend be home with you to help after the baby/babies are born? ____________________

If so, who, and for how long?_________________________________________________________

How long do you anticipate wanting postpartum doula support?

Number of days per week ________ Number of weeks ________ Best Time _________am _________pm (minimum of 5 hrs - coverage for two feedings )

What are your main reasons for choosing to have a postpartum doula? (Circle)
 

Instruction in Infant Care

Breastfeeding / Lactation Consultation

Prevention of Sleep Deprivation.

Emotional Support

Reassurance Sibling care

Household help Physical comfort measures

Extra pair of hands

I will be returning to work and I need to heal quickly

Have you had any complications with this pregnancy? Please describe:___________________________

____________________________________________________________________________________

Have you had any previous complications with fertility, reproductive health, pregnancy or

postpartum? Please describe:_____________________________________________________________

____________________________________________________________________________________

Have you had any stressful events, losses or major life changes in the last year? Please

describe:_____________________________________________________________________________

____________________________________________________________________________________

Please check any classes or support groups you have taken/ joined in preparation for postpartum

___ Infant care ___ Childbirth preparation ___ Breastfeeding ___ Infant CPR ___ Le Leche League International ____ Multiples Support Groups____ other

Have you cared for a baby recently? ______________________________________________________

What books on infant care, breastfeeding or postpartum have you read? __________________________

____________________________________________________________________________________

Does your family have any particular cultural or religious traditions that I should know about?_________

____________________________________________________________________________________

Does your family have any particular style of cooking or special dietary needs? ____________________

____________________________________________________________________________________

How will your baby be fed? _____ breast milk _____ formula _____ combination

Would you like help or support with feeding your baby? _______________________________________

Please rate how important you anticipate the following will be in your postpartum care:

(1)        Not at all important                  (5)        Very important
 

Postpartum comfort measures 1 2 3 4 5

Family’s basic needs (food, drink) 1 2 3 4 5

Holding baby 1 2 3 4 5

Infant care guidance 1 2 3 4 5

Help feeding baby 1 2 3 4 5

Household help 1 2 3 4 5

Emotional support 1 2 3 4 5

Sibling care 1 2 3 4 5

Is there anything else you’d like me to know about your family?_________________________________

_____________________________________________________________________________________

   Information provided during postpartum care services includes:

  Feeding baby / proper latch if breast feeding

  Diaper changing / types of stools / number of diapers per day

  Bathing baby

  Cord care

  Circumcision care

  Swaddling baby

  Burping baby

  Soothing baby

  Infant massage 

  CFT Therapy  (Gillespie Method Brain Score- Craniosacral Fascial Therapy)

  Carrying baby in a sling

  Postpartum comfort measures

  Information on mom’s physical restoration

  Information on emotional adaption

  Other: