Postpartum Doula Care

2700674.jpg

Postpartum Care Questionnaire

Sample of Questions

  • 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: