Welcome to Informed Birth Choices.  We are so happy you have chosen us for your birth doula services. The following information helps us provide you with the most customized service possible.  Please take the time to answer thoughtfully.  This information will be held in confidence by IBC.  Thank you for choosing Informed Birth Choices!

Mother's Name *
Mother's Name
Partner's Name
Partner's Name
Address *
Address
Mother's Cell Phone *
Mother's Cell Phone
Partner's Cell Phone *
Partner's Cell Phone
Due Date *
Due Date
Where do you plan to have your child?
(include pertinent details)
Personal Information
If yes, please explain.
If yes, please explain.
Interventions
Common Medical Interventions
Common Medical Interventions
Thinking about the following procedures, very few women would choose to have them for no reason. Assuming there was a good reason, how strongly would you agree to, or disagree to, the use of the following interventions? For example: If you do NOT want a cesarean you might choose "Strongly Disagree"
IV (fluids)
Saline lock
Induction
Continuous fetal monitoring
Internal fetal monitoring
Intrauterine pressure catheter
Pitocin for induction
Pitocin for augmentation
Prostaglandin gel
Cytotec (Misoprostol)
Artificial Rupture of Membranes
Post-delivery Pitocin
Vacuum extraction
Cesarean birth
Urinary catheter
Stirrups for birth
Episiotomy
Perineal tear
Narcotic (pain relief)
Epidural (pain relief)
Spinal
Coping Techniques & Pain Medication
Please also explain why you feel this way.
Coping Measures
Please check below the coping measures you are open to trying in labor. Select all that apply.
Pain Minimizers
*please consult with your care provider
Breathing Techniques *
Relaxation Techniques *
Position Changes *
Labor Stimulation Techniques
*Please consult with your care provider.
The Half Hour Rule *
About the Baby
Eye Ointment *
Vitamin K Injection *
PKU Test *
Hepatitis B
Circumcision
Bath
Questions or Comments