What Can I Do Right Now?
|
Date
|
| 1. Activity Level |
|
| Maintain a normal activity level |
__________ |
| Slightly decrease activity level |
__________ |
| Greatly decrease activity level |
__________ |
2. Working Outside the Home |
|
| Maintain my full-time job |
__________ |
| Work part-time (how many hours?) |
__________ |
| Work in my home (how many hours?) |
__________ |
| Stop work completely |
__________ |
| Why: ________________________________________________________ |
| 3. Working Inside the Home |
|
| Continue doing all housework |
__________ |
Decrease housework including:
Heavy lifting (laundry, moving furniture, etc) |
__________ |
| Preparing meals (standing on feet for a prolonged period of time) |
__________ |
| Vigorous scrubbing, vacuuming, etc |
__________ |
| Do not lift anything heavier than ________ pounds |
|
Other: ________________________________________________________ |
Why: _________________________________________________________ |
4. Child Care |
|
| Care for other children as usual |
__________ |
| No lifting children |
__________ |
| Have another caretaker watch an active toddler |
__________ |
| Have permanent caretaker for children |
__________ |
Why: _________________________________________________________ |
5. Mobility |
|
| Continue normal mobility |
__________ |
| Limit mobility (sit down frequently) |
__________ |
| Lie down each day (how many hours?) |
__________ |
| Recline all day (propped up) |
__________ |
| Lie down flat all day (on side?) |
__________ |
| May walk stairs |
__________ |
| Stairs forbidden |
__________ |
| Take a shower/wash hair (how often?) |
__________ |
| Eat lying down? |
__________ |
| Eat sitting up? |
__________ |
| Eat sitting at a table? |
__________ |
| Sit at computer? |
__________ |
| Lie down on side to use laptop computer? |
__________ |
Why: _________________________________________________________ |
6. Driving |
|
| May drive a car |
__________ |
| May be a passenger in a car (frequency?) |
__________ |
| May not ride in a car, except to doctor |
__________ |
Why: _________________________________________________________
|
| 7. Bathroom Privileges/Personal Hygiene |
|
| May use bathroom normally |
__________ |
| Should actively avoid constipation |
__________ |
| May not use bathroom (use bedpan) |
__________ |
| May shower or bathe _____ minutes each day |
__________ |
| May shower or bathe every ______ day(s) for ______ minutes |
__________ |
| May sponge bathe only |
__________ |
Why: _________________________________________________________
|
| 8. Sexual Relations |
|
| May continue normal sexual relations |
__________ |
| Should limit relations (maximum times a month?) |
__________ |
| Should avoid intercourse |
__________ |
| Should avoid all types of relations which stimulate female orgasm |
__________ |
Why: _________________________________________________________
|
| 9. Maintenance of Pregnancy |
|
| Should monitor fetal activity _______ hours each day by hand, counting movements |
__________ |
| Should drink wine each day (When? How much?) |
__________ |
| Should abstain from all alcohol |
__________ |
| Should limit cigarette smoking (# per day?) |
__________ |
| Should stop smoking cigarettes |
__________ |
| Should use monitor for contractions |
__________ |
Should take (drug): _____________________________________________ |
|
_______ times daily, dosage: __________________________________ |
|
Reason: ___________________________________________________ |
| Should take (drug): ______________________________________________ |
| _______ times daily, dosage: __________________________________ |
Reason: ___________________________________________________
Should follow these dietary rules: |
|
Plenty of: Protein, vegetables, fruits, calcium, other: |
|
__________________________________________________________ |
Avoid: Excess salt, excess fats, junk food, spicy foods, other:
__________________________________________________________ |
Approximate number of calories a day: __________________________
|
What Might I Expect In the Future? |
|
| 1. Will my plans for a homebirth change? |
__________ |
| Will I be referred to more intensive high-risk care? |
__________ |
| 2. Decrease in activity level |
__________ |
| 3. Limitations on work/stop work completely |
__________ |
| 4. Decrease housework |
__________ |
| 5. Need for child care helper |
__________ |
| 6. Need to recline bed |
__________ |
| Need to stay in bed (total bedrest) |
__________ |
| 7. Limit driving/stop driving |
__________ |
| 8. Limit sexual relations |
__________ |
| Abstain from sexual relations |
__________ |
| 9. Need to self-monitor fetal activity |
__________ |
| 10. Need to use a contraction monitor |
__________ |
| 11. Need to take labor-inhibiting drugs |
__________ |
| 12. Need to have a cervical stitch put in |
__________ |
| 13. Need to stay in hospital for some period of time |
__________ |
| 14. Need to have an amniocentesis or CVS |
__________ |
| 15. Need to have ultrasounds |
__________ |
| 16. Need to visit Midwife or Health Care Provider frequently |
__________ |
| 17. Need to visit to perinatologist (high-risk specialist) |
__________ |
| 18. Need to have alpha-fetal protein levels done |
__________ |
| 19. Need to have a blood sugar screening |
__________ |
| 20. Need to have non-stress tests |
__________ |
| 21. Need to have stress tests |
__________ |
If Problems Arise and I Go Into Premature Labor . . . |
|
| 1. When should I contact my Midwife or Heath Care Provider? |
__________ |
| 2. Where will I be hospitalized? |
__________ |
| 3. Where might I be transferred? |
__________ |
| 4. Name of Health Care Provider at other hospital? |
__________ |
| 5. Where would my premature baby be hospitalized? |
__________ |
| 6. Could my husband be present at delivery? |
__________ |
| 7. Is there a great possibility of a Cesarean? |
__________ |
Hospital Bedrest |
|
| 1. What position do I have to be in? |
__________ |
| 2. Do I have to use a bedpan? |
__________ |
| 3. Can I reach for things or should I use a reacher? |
__________ |
| 4. Personal hygiene |
|
| Can I take a shower? |
__________ |
| Can I take a bath? |
__________ |
| Can I get out of bed to wash my hair? |
__________ |
| 5. Mobility |
|
| Can I walk the halls? |
__________ |
| Can I walk in my room? If so, how often? |
__________ |
| Can I sit in the chair in my room? |
__________ |
| Can I take a wheelchair to the lobby? |
__________ |
| Can I take a wheelchair to the nursery? |
__________ |
| Can I take a wheelchair to hospital support group meetings? |
__________ |
| 6. Visitors |
|
| When can my husband visit? __________________________________ |
| Can other friends or family visit? ________________________________ |
|
Can children visit? ___________________________________________ |
| Who may be present in the delivery room? _______________________ |
| 7. Consults: |
|
| If appropriate, may I see: |
|
| A physical therapist |
__________ |
| An occupational therapist |
__________ |
| A neonatologist (about fetal development) |
__________ |
| A social worker |
__________ |
| Chiropractor |
__________ |
| Massage therapist |
__________ |
Other directions:
|
MoonDragon's Pregnancy Information: Coping With Bedrest
