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| Enter your name in the space provided |
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| Your Birthing Partner's Name |
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| Midwife and/or Obstetrician |
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| Name of Hospital or Birthing
Centre |
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| Paediatrician |
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| Enter the approximate due date |
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| DURING MY PREGNANCY I HAVE EXPERIENCED |
| Symphysis pubis dysfunction |
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One sided sacroiliitis |
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Pelvic Girdle Pain |
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| Diastasis Symphysis Pubis |
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Doubled sided sacroiliitis |
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| Other: |
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WHICH OF THESE ACTIVITIES HAVE BECOME DIFFICULT AND PAINFUL |
| Standing |
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Going to work |
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Cleaning the house |
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| Lifting |
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Sitting |
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Cooking meals |
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| Walking up stairs |
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Carrying |
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Driving a car |
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| Lying on my back |
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Walking down stairs |
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Shopping for groceries |
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| Caring for my other children |
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| Other: |
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| PAIN LEVEL GUIDELINE |
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I cannot stand |
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I cannot walk |
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I can't walk more than 3 meters/ 10
feet |
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I am in mild pain most of the day |
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I am in moderate pain most of the day
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I am in severe pain most of the day
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I am in disabling severe pain most of the day |
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Other: |
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| I WOULD LIKE MY ROOM TO HAVE |
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Dimmed Lights |
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To have Voices Respectfully Lowered |
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Include Music I Provide |
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Include Coping Aids for Pelvic
Pain...special pillows etc..... |
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Other: |
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| I would like to wear my own clothing "yes" or "no" |
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I would like my birthing partner to film and/or photograph at my request
"yes" or "no" |
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| I would like to keep internal vaginal exams to a
minimum "yes" or "no" |
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| I would prefer not to have my pubic hair shaved because of the symphysis pubis pain
"yes" or "no" |
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| I would like privacy to discuss my pain-relief
options before I make a decision "yes" or "no" |
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| Only offer me medication when I
ask "yes" or "no" |
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| Please suggest medications
if you see I am uncomfortable "yes" or "no" |
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| I WOULD LIKE TO TRY THESE THERAPIES |
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Massage |
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Guided Relaxation |
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Water [shower/bath]
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Hot/cold therapy |
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Acupressure
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Other: |
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| I WOULD LIKE TO USE THE FOLLOWING |
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Allowed freedom of movement |
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Walking epidural |
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Classic Epidural |
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Birthing Bed |
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Birthing Stool
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Birthing Chair |
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Birthing Pool/Tub |
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Other: |
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| POSITIONS I WOULD LIKE TO TRY |
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Side lying position with some one supporting my knee |
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Kneeling resting arms on bed/chair |
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Semi-reclining on bed, knees pressed to chest with some one helping to stabilize my knees |
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Other: |
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| Squatting is not the best position because |
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| Lying on my back with my legs in stirrups is not the best positions because |
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| If I require stitches I would prefer not to have my legs in stirrups because |
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| After the delivery I may require total bed rest because |
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| MT PAIN LEVEL AT THE MOMENT IS |
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Bad |
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Poor |
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Average |
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Fair |
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Good |
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| AFTER DELIVERY I MIGHT REQUIRE |
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Pain medication |
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Longer stay in hospital |
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Physiotherapist |
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Pelvic binder or belt |
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Options and care from other specialist's
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Other |
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| Before I go to the Maternity Ward I will need you to make sure the ward staff are
aware of my pelvic joint pain and will assist me with receiving treatment for my
unstable pelvis and organize the necessary aids to help make me more mobile...
add more if necessary in space below below. |
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