Hello, and thank-you for choosing me to be your doula.

I look forward to getting to know

you both and understanding how I can best support you in the birth of your baby.

To help prepare for our prenatal visits, I have sent you some worksheets to go through.
Please print them and try and fill them out before our first visit. The purpose of these is
to get you thinking about your hopes, concerns and plans for the birth.

The first worksheet is the “Birth Plan” and is two pages long. The Birth Plan is meant to
be a guide for everyone involved in your birth, as long as labour proceeds normally.
Ideally you can fill it out together. We will bring it to your labour for the hospital staff to
see, to help them understand you. If you like, you can take it to a prenatal appointment
for your doctor or midwife to review.

The second worksheet is about roles and expectations. There is one worksheet for the
expecting mum, and one for the expecting dad. Please fill them out individually. This will
facilitate discussion of how we can work together to ensure a positive experience for you
both.

If you are unsure of anything, please leave it blank and we will discuss it and fill it in
later. We will cover everything in this document… and much more!

I’m excited to be a part of your pregnancy and birth. Look forward to seeing you soon.

Wendy

Wendy Frasca

wendy@birthstonesdoula.ca
604-649-8843
 BIRTH PLAN – Page 1 of 2

First names / nicknames of expecting parents:

People who will be present at your birth, and their relationship to you:

Are non-essential people (i.e. students) welcome at your birth? Yes___ No___

As long as labour proceeds normally, having a natural childbirth is _________________

important to me (very, somewhat, not)

Do you have any health concerns, pregnancy or non-pregnancy related?

What are your greatest worries in terms of childbirth? (Ex., tearing, surgery, etc.)

Do you want the freedom to use a variety of positions in the birthing stage? (Ex. standing,
squatting, on hands and knees)

Do you have any specific requests for the birth? (Ex. water birth)

Are there any procedures you want to avoid, unless absolutely necessary? (Ex. episiotomy,
vacuum, forceps, etc.)

Who should cut the babies cord?

Wendy Frasca, Birth Doula | wendy@birthstonesdoula.ca | 604.649.8843

 BIRTH PLAN – Page 2 of 2

PAIN MEDICATIONS

Please indicate which response best reflects how you feel about pain medications and epidurals.
If you are not yet sure, please leave it blank for now.

USE OF EPIDURAL ANASETHESIA

o I want to avoid an epidural and feel strongly about this; please do not offer me one.
o I would prefer not to have one; please talk to my support people first.
o I will consider using one when I am in active labour.
o I plan to have an epidural and would order it ahead of time if I could.

USE OF OTHER PAIN MEDICATIONS

o I want to avoid them and feel strongly about this; please do not offer them to me.
o I would prefer not to use them; please talk to my support people first.
o I will consider using them.
o Hook me up with all you’ve got once I’m in my room.

COMFORT MEASURES FOR LABOUR

Please circle the comfort measures that you would consider trying in labour (you can cross out
anything you do not want). If you are uncertain and need more clarification on any item, just leave
it blank for now. We will go through each comfort measure in detail.

o Movement (walking, rocking)

o Shower
o Bath
o Hot packs
o Cold packs
o Acupressure

• Any areas to avoid? (Ex. feet, legs, back, shoulders, hands)

o Massage

• Any areas to avoid? (Ex. feet, legs, back, shoulders, hands)

o Birthing ball
o Focal points, such as a photo or meaningful item
o Guided visualization
o Music
o Low lighting
o Prayer

Wendy Frasca, Birth Doula | wendy@birthstonesdoula.ca | 604.649.8843

Other:

Wendy Frasca, Birth Doula | wendy@birthstonesdoula.ca | 604.649.8843

ROLES AND EXPECTATIONS

The next two pages are similar. One is to be filled out by the expecting mother and one to be
filled out by the partner. Please be as honest as possible.

For the expecting mother.

How do you think you may behave in labour?

What role do you see you partner playing in labour? Very involved, somewhat involved, hanging
back.

Within that role, what expectations do you have of your partner? How do you hope he will act?
How do you want him to help? Consider each stage of labour… early on at home, upon arrival at
hospital, in the birthing room.

What expectations do you have of me and how can I help?

Wendy Frasca, Birth Doula | wendy@birthstonesdoula.ca | 604.649.8843

ROLES AND EXPECTATIONS

For the expecting father.

How do you think your partner may behave in labour?

What role do you see yourself playing in labour? Very involved, somewhat involved, hanging
back.

Within that role, what expectations do you have of yourself? How do you plan to help? Consider
each stage of labour… early on at home, upon arrival at hospital, in the birthing room.

When the baby is ready to be born, do you see yourself watching his/her birth, or up by your
partner’s head?

What expectations do you have of me? How can I help you?

Wendy Frasca, Birth Doula | wendy@birthstonesdoula.ca | 604.649.8843