CHILDBIRTH INFORMATION RECORD
DATE:________________
EDD:_________________
HOME
HOSPITAL
WATER
IF Hospital;
Confirmed by U/S:
Y N
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 that you will meet up to four highly skilled, experienced, and like-minded doulas during your 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, eliminating the need for a back-up doula with whom you may have not met
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 csection 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 csection 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
Onset of Labour
Pain Relief
Perineal Care
Spontaneous
Medically Induced
Sweeping membranes
Rupture of membranes
Cervidil
Prepidil
Foley bulb
Pitocin
Alternatives
Acupuncture
Acupressure
Herbs/Essential oils
Nipple stimulation
Epidural
Narcotic
Sterile water injections
Massage
Warm compress
Episiotomy
Prefer tear to episiotomy
Monitoring
None
Handheld Doppler
Intermittent
Continuous
Internal
Environment
Lighting
Electric candles
Music/sound machine
Aromatherapy
Door closed/open
Wear own clothes/hospital gown
Partner support
Doula support
Birth photographed or videotaped
Birth photographed or videotaped
Positions
Standing
Walking
Stair climbing
Standing/leaning against bed
Standing/leaning against birth ball
Slow dancing
Standing lunge
Kneeling lunge
Sitting upright
Sitting on toilet
Sitting on birth ball
Sitting/leaning forward w/ support
Rocking
Semisitting
Side-lying
Hands and knees
Open knee-chest
Squatting
Speeding up Labour
Nothing
Nipple stimulation
Acupressure
Position changes
Rupture of membranes
Pitocin
Hydration/Food
Pushing
Snacks/fluids as desired
Ice chips
IV fluids
Honey sticks or popsicles
Spontaneous
Directed
Passive descent
No time limit
Mirror
No coaching
Comfort Measures
Massage
Shower/Bathtub
Hot/Cold packs
TENS Unit
Vocalization
Breathing
Visualization
Focal point
Cutting Cord
Partner/Other
Doctor/Midwife
Immediately
Wait until it stops pulsating
Lotus
Baby’s Assessment
On Mother
In warmer
Partner announce gender
Eye Care/Injections
Immediately
Delayed
Declined
Cesarean
Partner present/Doula present
Epidural/Spinal
One arm free
Lower drape to view birth
Describe events
Environment
Music
Aromatherapy
Essential talk only
Lowered machine sounds
Breastfeed in OR
Rooming
24 hour with mother
Partner rooming in
Delivery Positions
Feeding
Semisitting
Side-lying
Hands and knees
Squatting
In water
Breastfeeding
No bottles/pacifiers/formula
Pumped milk
Cup
Finger
Formula
SUMMARY OF LABOUR/BIRTH
Client Information
Name
Partner’s Name
Due Date
Initial Birth Plan □ Unknown □ Natural □ Medicated
Labour & Birth
Birth Date
Labour length
Location of delivery □ Hospital
□ Home
Doctor/Midwife
Interventions
□ Prostaglandin induction
□ Cytotec/Cervadil induction
□ Pitocin induction
□ Pitocin augmentation
□ AROM
□ Intermittent EFM
□ Continuous EFM
□ Other
Medications
□ Stadol
□ Nubain
□ Demerol
□ Sterile Water Injections
□ Epidural before 5cm
□ Epidural after 5cm
□ Spinal
□ General Anesthesia
Method of Birth
□ Vaginal
□ Forceps
□ Vacuum
□ VBAC
□ Repeat Cesarean
□ Unexpected Cesarean
□ Planned Cesarean
Newborn
Name
Weight
Outcome
□ Normal □ Premature □ Postmature □ Stillbirth □ Defect
Postpartum
□ Rooming in □ Nursery □ NICU □ Breastfeeding
Notes
Sex □ M □ F
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
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
□ Yes □ No
10. How did you learn about our services?
Additional Comments
RESOURCES
Yoga
Prenatal Yoga and Postpartum Mom & Baby with Laurel Hicks 519 564-1326 or www.mindfulmamasyoga.com
Prenatal Renee Trepanier @ Blossoming Lotus Yoga LaSalle
Full Studio Jayne Chichon @ Bright Yoga in Essex and Eastside Yoga in Windsor
Preschool to Preteen - Stephanie Renaud @ 519-564-1948 stephanie.a.renaud@gmail.com
Acupuncture
Dr Hong Sun - Sun's Acupuncture, 1923 University Avenue West Windsor 519 254-1165
Dr.Ruth E. Strausz, Chiropractic Wellness Centre, 1405 Tecumseh Road W. 519 254-0777
Pre and Post Natal Massage RMT
Ann Switzer, RMT Advanced training in prenatal massage 519-253-9402
Rhea Eady, RMT 519 259 9560
Breastfeeding
Dr. Jack Newman
He has a clinic in Toronto, videos on-line and youtube for troubleshooting a DVD and a great book available on-line
or chapters. www.drjacknewman.com
Becky Campeau International Board Certified Lactation Consultant – Border City Breastfeeding
519 564 0358 www.bordercitybreastfeeding.com
Provides in-home consultations
Diane Pepin
Another wonderful local women and mother of 4 who is trained in breastfeeding in-home support.
1-877-256-3541 or 519-566-7687
Le Leche League of Windsor
www.lllc.ca/chapter-group/windsor-essex-county
They offer a wide variety of classes and are great resource prenatally and postnatal for peer support and
professionally trained help. Typical meeting can include;
Meeting 1: The Advantages of Breastfeeding to Mother and Baby
Meeting 2: Baby Arrives: The Family and the Breastfed Baby
Meeting 3: The Art of Breastfeeding and Avoiding Difficulties
Meeting 4: Nutrition and Weaning
Placenta Encapsulation
Jennifer Cox 519-258-7367
Stacey Trottier-Mousseau 519 715 9463
Maternal Reflexology
Heather Torti 519 978 0053
Local Shopping
All About Birth www.allaboutbirthboutique.ca A Canadian birth boutique located right here in Windsor
Enchie Mart www.enchie.com 519 250 3566 located at 2001 Provincial Road
West Grand Pharmacy 519 966-8621 located at 2950 Dougall
Midwives
Midwives of Windsor 3357 Walker Road Windsor, ON N8X 4W4 (519) 252-4784
Midwifery Collective of Windsor Essex 1455 Pelissier St Windsor, ON N8X 1M7 (519) 252-4700
Loss and Greif Counseling
Local independent counseling
Gisele Harrison MSW, RSW, RYT 519 816 2701
Nancy Praill, MSW, RSW, Psychotherapist 1-877 454 0337
Public Health
Canadian Mental Health – Bereavement Resource Program 519 255 7440
Water Birth Tub Rentals
Diane Pepin
519 566 7687
Gillian Slate
519 990 4745
Photographers – Prenatal, Birth, Family, Newborn
Sherri Peroni
(519) 890-1244 www. sherriperoniphotography.com
Stephanie Lynn Kid
(519) 980-5967 www.slpphotos.blogspot.com
Cloth Diapering & Baby Wearing
Diane Pepin – Baby wearing Expert (519) 566 7687
Car Seat Safety
Gillian Slate – Owner of CREW and Birth Windsor. Call (519) 990-4745 or email info@birthwindsor.com
The Safety Village (519) 258 2146 ext 1350 www.thesafetyvillage.com
This link provides all the car seat safety checks within the city
Recommended Reading
Ina May Gaskin Guide to Childbirth (Available at Chapters or on-line)
Ina May Gaskin Guide to Breastfeeding (Available at Chapters or on-line)
Labour Progress by Penny Simkin
The Birth Partner by Penny Simkin
Birthing From Within by Pam England
Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Edition written by
Penny Simkin, April Bolding, Janelle Durham, Janet Whalley, & Ann Keppler
HypnoBirthing: The Mongan Method: A natural approach to a safe, easier, more comfortable birthing (3rd Edition)
On-Line Resources Supporting Informed Choice/Evidence Based Birth
Gloria Lemay – Previously a registered midwife and now an unregistered birth attendant in Vancouver BC. One of
the busiest ladies around! She has a great blog and a website with loads of evidence based information.
www.glorialemay.com
Ina May Gaskin - An activist and midwife who runs a traditional school of midwifery in the USA known as the farm
www.inamay.com
Indie Birth - To fire up the minds of modern-day mamas, so that they are inspired, educated and aware of all the
choices surrounding them concerning their pregnancies and births.
To cater to those that are already independent, free-thinking and maybe a little bit radical… and to transform
those mamas not yet in touch with their instinctive abilities to birth and nurture naturally.
http://www.indiebirth.com
Trust Birth – A volunteer organization geared towards telling the truth surrounding birth. A focus on trust and
dispeling what our cultural norms tell us to believe. www.trustbirth.com
Motherisk is a fantastic website dedicated to the unborn. Loaded with information on what medications are safe
during pregnancy & breastfeeding, cancer, morning sickness etc. www.motherisk.org
Evidence Based Birth – A fantastic place to obtain the most evidence based research in lay terms. Rebecca L.
Dekker, PhD, RN, APRN is the founder and author of Evidence Based Birth. Rebecca is an assistant professor of
nursing at a research university in the U.S. She teaches pathophysiology and pharmacology to BSN nursing
students, and she serves as a mentor for doctoral students in Nursing.
Rebecca realized that it was very difficult for the average person to find information about evidence-based
maternity care. Realizing that she had the research and writing skills to meet this need, Rebecca coined the term
“evidence based birth” and founded www.evidencebasedbirth.com. The mission of Evidence Based Birth is to
promote evidence-based practice during childbirth by providing research evidence directly to women and families
Local Postnatal Support
Life with a Baby – Windsor www.windsor.lifewithababy.com
A peer support program providing ongoing practical and emotional PEER-based support for new and expecting
parents, and parents of children up to the age of six. They have monthly events for parents and kids to get out and
have fun while also learning about the available resources in the community.
Ontario Early Years A place where parents and caregivers can take part with their children in a range of programs
and activities, get answers to questions, get information about programs and services that are available for young
children and their families and talk to early years professionals, as well as other parents and caregivers in the
community.
Mamas Group on Facebook is a fantastic local resource for late night questions etc. There are over 1000 local
mothers who write daily about everything from poop, sleep to drinking alcohol while nursing. It is a secret group
so you have to ask a member to join. We doulas are all members, so ask away!