1. When would you like me to come to the birth center/hospital?
   1. _____Water breaks
   2.  _____Contractions _____ minutes apart for _______ long
2. What are your recommendations if water breaks before contractions?
   1. _____Call and stay home until contractions start
   2. _____Come to office/hospital/birth center to monitor baby and then return home
   3. _____Come immediately to hospital/birth center
3. How long after water breaks would you recommend starting pitocin?
4. What is your philosophy regarding episiotomies? Under what circumstances would you perform them? What percentage of the time do you and your partners perform episiotomies?
5. What is your protocol or routine regarding the following:
   1. IV’s
   2. Continuous monitoring
   3. Eating/Drinking
   4. Walking during labor
   5. Walking with ruptured membranes
   6. Showering/Bathing
   7. AROM at ______ cm
   8. Internal Monitoring
   9. Pitocin post-delivery
6. How do you feel about natural/unmedicated birth?
7. Are you comfortable with doulas?
8. If I chose to use an epidural, when would you recommend I receive it?
9. Under what circumstances would you recommend an induction of labor?
10. How long after my due date will we wait before inducing labor?
11. Do you routinely use Cytotec or Prostaglandin gel to ripen the cervix before inductions?
12. Do you believe in active management?  (Progress <1cm per hour will call for AROM or pitocin)
13. What non-medical ways of stimulating labor do you recommend?
    1. Herbs  ____
    2. Nipple Stimulation ____
    3. Castor Oil _____
    4. Intercourse (before SROM) _____
    5. Enema _____
    6. Acupuncture _____
    7. None _____
14. How do you define “failure to progress? “How long would we wait before doing a cesarean?
15. What is your C-section rate?  What are the 2 most common reasons you perform a c-section?
16. What positions for the delivery are you comfortable with?
    1. Lying down_____
    2. Side-lying ____
    3. Hands/Knees or knee chest _____
    4. Squatting _____
    5. Semi-sitting _____
    6. Semi-sitting in stirrups only ____
    7. *Do you insist on “breaking down” the bed?
17. Are you supportive of VBAC? What is your VBAC rate?  What are your standard routines for VBAC mothers?
18. Who is your back-up? Under what circumstances would I see him/her?

(Karina Bolger, AAHHC, revised and adapted from Kelli Way, 2000)