Lumina Birth - Doula's Post-Birth Summary Survey

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1. Doula

	Doula
Primary Doula	Doula Primary Doula Doula
Backup Doula	Backup Doula Doula
Apprentice Doula	Apprentice Doula Doula

Comments

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2. Client Names

Client Names Mother's Name
Father/Partner
Baby's Name
Boy or Girl
Info on Multiples

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3. Baby's Dates

	MM		DD		YYYY
EDD	Baby's Dates EDD Month	/	Day	/	Year
Birth Date	Birth Date Month	/	Day	/	Year

4. Birth Location

	Home	Piedmont	Northside	Dekalb	Emory Midtown	North Fulton	Gwinnet Medical	Kennessaw	Other
Birth	*Birth Location Birth Home	Birth Piedmont	Birth Northside	Birth Dekalb	Birth Emory Midtown	Birth North Fulton	Birth Gwinnet Medical	Birth Kennessaw	Birth Other

Other (please specify)

5. A Few Numbers...

	1st	2nd	3rd	4th	5th+	1-3 hrs	4-6 hrs	7-9 hrs	10-12 hrs	13-15 hrs	16-19 hrs	20-22 hrs	23-25 hrs	26+ hrs	36th wk	37th wk	38th wk	39th wk	40th wk	41st wk	42nd wk
What number birth for the mother?	*A Few Numbers... What number birth for the mother? 1st	What number birth for the mother? 2nd	What number birth for the mother? 3rd	What number birth for the mother? 4th	What number birth for the mother? 5th+	What number birth for the mother? 1-3 hrs	What number birth for the mother? 4-6 hrs	What number birth for the mother? 7-9 hrs	What number birth for the mother? 10-12 hrs	What number birth for the mother? 13-15 hrs	What number birth for the mother? 16-19 hrs	What number birth for the mother? 20-22 hrs	What number birth for the mother? 23-25 hrs	What number birth for the mother? 26+ hrs	What number birth for the mother? 36th wk	What number birth for the mother? 37th wk	What number birth for the mother? 38th wk	What number birth for the mother? 39th wk	What number birth for the mother? 40th wk	What number birth for the mother? 41st wk	What number birth for the mother? 42nd wk
What number birth with a doula?	What number birth with a doula? 1st	What number birth with a doula? 2nd	What number birth with a doula? 3rd	What number birth with a doula? 4th	What number birth with a doula? 5th+	What number birth with a doula? 1-3 hrs	What number birth with a doula? 4-6 hrs	What number birth with a doula? 7-9 hrs	What number birth with a doula? 10-12 hrs	What number birth with a doula? 13-15 hrs	What number birth with a doula? 16-19 hrs	What number birth with a doula? 20-22 hrs	What number birth with a doula? 23-25 hrs	What number birth with a doula? 26+ hrs	What number birth with a doula? 36th wk	What number birth with a doula? 37th wk	What number birth with a doula? 38th wk	What number birth with a doula? 39th wk	What number birth with a doula? 40th wk	What number birth with a doula? 41st wk	What number birth with a doula? 42nd wk
Approximate hours doula spent with client at labor/birth?	Approximate hours doula spent with client at labor/birth? 1st	Approximate hours doula spent with client at labor/birth? 2nd	Approximate hours doula spent with client at labor/birth? 3rd	Approximate hours doula spent with client at labor/birth? 4th	Approximate hours doula spent with client at labor/birth? 5th+	Approximate hours doula spent with client at labor/birth? 1-3 hrs	Approximate hours doula spent with client at labor/birth? 4-6 hrs	Approximate hours doula spent with client at labor/birth? 7-9 hrs	Approximate hours doula spent with client at labor/birth? 10-12 hrs	Approximate hours doula spent with client at labor/birth? 13-15 hrs	Approximate hours doula spent with client at labor/birth? 16-19 hrs	Approximate hours doula spent with client at labor/birth? 20-22 hrs	Approximate hours doula spent with client at labor/birth? 23-25 hrs	Approximate hours doula spent with client at labor/birth? 26+ hrs	Approximate hours doula spent with client at labor/birth? 36th wk	Approximate hours doula spent with client at labor/birth? 37th wk	Approximate hours doula spent with client at labor/birth? 38th wk	Approximate hours doula spent with client at labor/birth? 39th wk	Approximate hours doula spent with client at labor/birth? 40th wk	Approximate hours doula spent with client at labor/birth? 41st wk	Approximate hours doula spent with client at labor/birth? 42nd wk
How long was the labor in total (best guess)?	How long was the labor in total (best guess)? 1st	How long was the labor in total (best guess)? 2nd	How long was the labor in total (best guess)? 3rd	How long was the labor in total (best guess)? 4th	How long was the labor in total (best guess)? 5th+	How long was the labor in total (best guess)? 1-3 hrs	How long was the labor in total (best guess)? 4-6 hrs	How long was the labor in total (best guess)? 7-9 hrs	How long was the labor in total (best guess)? 10-12 hrs	How long was the labor in total (best guess)? 13-15 hrs	How long was the labor in total (best guess)? 16-19 hrs	How long was the labor in total (best guess)? 20-22 hrs	How long was the labor in total (best guess)? 23-25 hrs	How long was the labor in total (best guess)? 26+ hrs	How long was the labor in total (best guess)? 36th wk	How long was the labor in total (best guess)? 37th wk	How long was the labor in total (best guess)? 38th wk	How long was the labor in total (best guess)? 39th wk	How long was the labor in total (best guess)? 40th wk	How long was the labor in total (best guess)? 41st wk	How long was the labor in total (best guess)? 42nd wk
Gestational week at time of birth?	Gestational week at time of birth? 1st	Gestational week at time of birth? 2nd	Gestational week at time of birth? 3rd	Gestational week at time of birth? 4th	Gestational week at time of birth? 5th+	Gestational week at time of birth? 1-3 hrs	Gestational week at time of birth? 4-6 hrs	Gestational week at time of birth? 7-9 hrs	Gestational week at time of birth? 10-12 hrs	Gestational week at time of birth? 13-15 hrs	Gestational week at time of birth? 16-19 hrs	Gestational week at time of birth? 20-22 hrs	Gestational week at time of birth? 23-25 hrs	Gestational week at time of birth? 26+ hrs	Gestational week at time of birth? 36th wk	Gestational week at time of birth? 37th wk	Gestational week at time of birth? 38th wk	Gestational week at time of birth? 39th wk	Gestational week at time of birth? 40th wk	Gestational week at time of birth? 41st wk	Gestational week at time of birth? 42nd wk

Other (please specify), and number if "+" above.

6. Care Provider Information

Care Provider Information Primary Attending Care Provider (ob/gyn, cnm, cpm)
Other Care Provider(s) [docs or midwives]
Physician's Group Name
Nurse(s) [if noted during birth]
Baby Care Nurse [if noted]

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7. Birth Outcome

Birth Outcome Vaginal

Vaginal Water Birth

VBAC

Cesarean Unplanned

Cesarean Scheduled

Other or Comments

8. Doula Support & Natural Labor

	Yes	No	N/A
Lumina Birth Childbirth Class	*Doula Support & Natural Labor Lumina Birth Childbirth Class Yes	Lumina Birth Childbirth Class No	Lumina Birth Childbirth Class N/A
Lumina Birth Breastfeeding Class	Lumina Birth Breastfeeding Class Yes	Lumina Birth Breastfeeding Class No	Lumina Birth Breastfeeding Class N/A
Other Childbirth Class	Other Childbirth Class Yes	Other Childbirth Class No	Other Childbirth Class N/A
Prenatal Alternative Health Care	Prenatal Alternative Health Care Yes	Prenatal Alternative Health Care No	Prenatal Alternative Health Care N/A
Pregnancy Massage	Pregnancy Massage Yes	Pregnancy Massage No	Pregnancy Massage N/A
Prenatal Yoga or Fitness	Prenatal Yoga or Fitness Yes	Prenatal Yoga or Fitness No	Prenatal Yoga or Fitness N/A
Good Pregnancy Nutrition	Good Pregnancy Nutrition Yes	Good Pregnancy Nutrition No	Good Pregnancy Nutrition N/A
Water Broke Before Contractions Began	Water Broke Before Contractions Began Yes	Water Broke Before Contractions Began No	Water Broke Before Contractions Began N/A
Water Broke unassisted during labor (SROM)	Water Broke unassisted during labor (SROM) Yes	Water Broke unassisted during labor (SROM) No	Water Broke unassisted during labor (SROM) N/A
Walking	Walking Yes	Walking No	Walking N/A
Eating & Drinking in Labor	Eating & Drinking in Labor Yes	Eating & Drinking in Labor No	Eating & Drinking in Labor N/A
Nipple Stimulation	Nipple Stimulation Yes	Nipple Stimulation No	Nipple Stimulation N/A
Birth Ball	Birth Ball Yes	Birth Ball No	Birth Ball N/A
Shower/Bath	Shower/Bath Yes	Shower/Bath No	Shower/Bath N/A
Massage in Labor	Massage in Labor Yes	Massage in Labor No	Massage in Labor N/A
Music	Music Yes	Music No	Music N/A
Hypnotherapy	Hypnotherapy Yes	Hypnotherapy No	Hypnotherapy N/A
Aromatherapy	Aromatherapy Yes	Aromatherapy No	Aromatherapy N/A
Visualization	Visualization Yes	Visualization No	Visualization N/A
Various Labor Positions	Various Labor Positions Yes	Various Labor Positions No	Various Labor Positions N/A
Birth Position of Choice	Birth Position of Choice Yes	Birth Position of Choice No	Birth Position of Choice N/A
Baby Given Immediately to Mother	Baby Given Immediately to Mother Yes	Baby Given Immediately to Mother No	Baby Given Immediately to Mother N/A
Mother/Baby Postpartum Bonding 30+ min. Before Baby Procedures	Mother/Baby Postpartum Bonding 30+ min. Before Baby Procedures Yes	Mother/Baby Postpartum Bonding 30+ min. Before Baby Procedures No	Mother/Baby Postpartum Bonding 30+ min. Before Baby Procedures N/A
Breastfed Baby Before Baby Procedures	Breastfed Baby Before Baby Procedures Yes	Breastfed Baby Before Baby Procedures No	Breastfed Baby Before Baby Procedures N/A

Other (please specify)

9. Interventions & Conditions

	Yes	No	N/A
Group B Strep (pos-yes, neg-no)	*Interventions & Conditions Group B Strep (pos-yes, neg-no) Yes	Group B Strep (pos-yes, neg-no) No	Group B Strep (pos-yes, neg-no) N/A
Pre-Eclampsia/PIH	Pre-Eclampsia/PIH Yes	Pre-Eclampsia/PIH No	Pre-Eclampsia/PIH N/A
Hep Lock Vein Port Inserted	Hep Lock Vein Port Inserted Yes	Hep Lock Vein Port Inserted No	Hep Lock Vein Port Inserted N/A
Water Broke by Care Provider (AROM)	Water Broke by Care Provider (AROM) Yes	Water Broke by Care Provider (AROM) No	Water Broke by Care Provider (AROM) N/A
IV Fluids	IV Fluids Yes	IV Fluids No	IV Fluids N/A
IV Antibiotics	IV Antibiotics Yes	IV Antibiotics No	IV Antibiotics N/A
Food or Fluids by Mouth Denied	Food or Fluids by Mouth Denied Yes	Food or Fluids by Mouth Denied No	Food or Fluids by Mouth Denied N/A
Pitocin Induction	Pitocin Induction Yes	Pitocin Induction No	Pitocin Induction N/A
Cervidil Induction	Cervidil Induction Yes	Cervidil Induction No	Cervidil Induction N/A
Cytotec Induction	Cytotec Induction Yes	Cytotec Induction No	Cytotec Induction N/A
Pitocin Augmentation	Pitocin Augmentation Yes	Pitocin Augmentation No	Pitocin Augmentation N/A
Narcotic for Pain Management	Narcotic for Pain Management Yes	Narcotic for Pain Management No	Narcotic for Pain Management N/A
Epidural	Epidural Yes	Epidural No	Epidural N/A
Continuous EFM	Continuous EFM Yes	Continuous EFM No	Continuous EFM N/A
Foley Catheter	Foley Catheter Yes	Foley Catheter No	Foley Catheter N/A
IUPC (internal pressure catheter)	IUPC (internal pressure catheter) Yes	IUPC (internal pressure catheter) No	IUPC (internal pressure catheter) N/A
IFM (internal fetal monitor)	IFM (internal fetal monitor) Yes	IFM (internal fetal monitor) No	IFM (internal fetal monitor) N/A
Episiotomy	Episiotomy Yes	Episiotomy No	Episiotomy N/A
Coached 2nd Stage	Coached 2nd Stage Yes	Coached 2nd Stage No	Coached 2nd Stage N/A
Breech Presentation	Breech Presentation Yes	Breech Presentation No	Breech Presentation N/A
Suction	Suction Yes	Suction No	Suction N/A
Forceps	Forceps Yes	Forceps No	Forceps N/A
Lithotomy Birth Position	Lithotomy Birth Position Yes	Lithotomy Birth Position No	Lithotomy Birth Position N/A
Postpartum Pitocin	Postpartum Pitocin Yes	Postpartum Pitocin No	Postpartum Pitocin N/A
Baby Given First Warmer/Nurse, not Mother	Baby Given First Warmer/Nurse, not Mother Yes	Baby Given First Warmer/Nurse, not Mother No	Baby Given First Warmer/Nurse, not Mother N/A
VBAC	VBAC Yes	VBAC No	VBAC N/A
If Cesarean, Were You Present for the Surgery	If Cesarean, Were You Present for the Surgery Yes	If Cesarean, Were You Present for the Surgery No	If Cesarean, Were You Present for the Surgery N/A

Other (please specify)

10. Please write a brief story of the birth and any other comments. Thank you so much!

Please write a brief story of the birth and any other comments. Thank you so much!

Lumina Birth - Doula's Post-Birth Summary
Exit this survey

1. Default Section

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1. Doula

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2. Client Names

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3. Baby's Dates

4. Birth Location

5. A Few Numbers...

6. Care Provider Information

*
7. Birth Outcome

8. Doula Support & Natural Labor

9. Interventions & Conditions

10. Please write a brief story of the birth and any other comments. Thank you so much!

Lumina Birth - Doula's Post-Birth SummaryExit this survey

1. Default Section

*1. Doula

*2. Client Names

*3. Baby's Dates

4. Birth Location

5. A Few Numbers...

6. Care Provider Information

*7. Birth Outcome

8. Doula Support & Natural Labor

9. Interventions & Conditions

10. Please write a brief story of the birth and any other comments. Thank you so much!

Lumina Birth - Doula's Post-Birth Summary
Exit this survey

*
1. Doula

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2. Client Names

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3. Baby's Dates

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7. Birth Outcome