Pelvic Instability Network Support (PINS)
Supporting women online since 2005
  
Enter your name in the space provided below.
 
 
 
Your Birthing Partner(s)
 
 
 
Midwife and/or Obstetrician
 
 
 
Name of Hospital or Birthing Center
 
 
 
Paediatrician
  
 
 
Enter the approximate due date
 
 
 
During my pregnancy I have had
 
Symphysis pubis dysfunction   One sided sacroiliitis   Pelvic Girdle Pain  
Diastasis Symphysis Pubis   Doubled sided sacroiliitis      
Other:      
 
The following movements have become difficult to do an/or sustain
 
standing    going to work   cleaning the house  
 lifting    sitting   cooking meals  
walking up stairs    carrying   driving a car  
 lying on my back    walking down stairs   shopping for groceries  
 caring for my other children          
other:          
 
Guideline for pain level
 
   I cannot stand
   I cannot walk
   I can't walk more than 3 meters/ 10 feet
   I am in mild pain most of the day
   I am in moderate pain most of the day
    I am in severe pain most of the day
    I am in disabling severe pain most of the day
  Other:

I would like my environment to have
 
  Dimmed Lights
  To have Voices Respectfully Lowered
  Include Music I Provide
   Include Coping Aids for Pelvic Pain...special pillows etc.....
  Other:
 
I would like to wear my own clothing (write "yes" or "no")
 
 
 

I would like my birthing partner to be able to film and/or photograph at my request

(write "yes" or "no")
 
 
 
I would like to keep internal vaginal exams to a minimum(write "yes" or "no")
 
 
 
I would prefer not to have my pubic hair shaved because of the symphysis pubis pain
(write "yes" or "no")
 
 
 
I would like some privacy to discuss my pain-relief options before I make a decision
(write "yes" or "no")
 
 
 
Only offer me medication when I ask(write "yes" or "no")
 
 
 
Please suggest medications if you see I am uncomfortable(write "yes" or "no")
 
 
 
I would like to try these non-medical therapies
 
    Massage
    Guided Relaxation
    Water [shower/bath]
    Hot/cold therapy
    Acupressure
    Other:
 
If available I would like to use the following
 
    Allowed freedom of movement
    Walking epidural
    Classic Epidural
    Birthing Bed
    Birthing Stool
    Birthing Chair
    Birthing Pool/Tub
    Other:
 
Positions I would like to try During the Pushing and Delivery
 
    Side lying position with some one supporting my knee
    Kneeling resting arms on bed/chair
    Semi-reclining on bed, knees pressed to chest with some one helping to stabilize my knees
    Other:
 
Squatting or lying on my back with my legs in stirrups aren't the best positions for me to be in because of the pelvic pain or other :
 
 

 
 
If I require stitches I would prefer not to have my legs in stirrups because....write in box below 
 
 

 
 
After the delivery I may require total bed rest because my ability to move around is....write in box below 
 
    Bad
    Poor
    Average
    Fair
    Good
 
Due to my pelvic pain, after the delivery I might require the following
 
    Pain medication
    Longer stay in hospital
    Physiotherapist
    Pelvic binder or belt
    Options and care from other specialist's
    Other
 
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 box below.