Mai Doula Comprehensive Assessment Tool for Breastfed Babies
We'll use this questionnaire together to help assess how your breastfeeding is going. You can fill it out on your own or with your support partner. When completed, it becomes a time saver to help me assess where the issues are. I suggest doing this form with your favorite music on and take your time because I know it's pretty long.
(c) 2012 Maiysha Campbell, CD(DONA), CLC, 917.771.2847.
Mom's Name *
Your answer
Baby's Name *
Your answer
Partners name
Your answer
You and your baby
Baby's Date of Birth *
Your answer
Baby's age today? *
Your answer
Baby's Due Date *
If you had two due dates, use the most recent due date given
Your answer
Birth Location *
Your answer
OB/Midwifery practice *
What is the name of the person/s who helped deliver your baby?
Your answer
Contact info: phone, email, address *
Your answer
Description of labor and delivery and the immediate postpartum, including all interventions and time *
Length, IVs, epidural at what point, how long, pitocin at what point and how long, vacuum, forceps, hours pushing, presentation, immediate afterbirth experience, etc
Your answer
Questions about the baby
Did your baby weight more than 5.5 pounds at birth? *
How much did your baby weigh at birth? *
Your answer
How much do they weigh today? *
Your answer
Calculate how many ounces per day your baby has put on. Has it been at least or very close to one ounce per day?
How much weight have they put on since birth? *
Your answer
Is your pediatrician concerned with baby's weight gain or lack of weight gain? *
If yes, please explain.
Your answer
Do you find it convenient to nurse when your baby wants to nurse? *
Does your baby have fussy times? *
Has your baby had a bowel movement in the last 24 hours? *
Has your baby had at least 6 wet diapers since hospital discharge?
Or within the last 24 hours if you have been home for more than a few days.
Did your baby have at least four poops per day by day four?
How many bowel movements has your baby had in the last 24 hours? *
Does your baby sleep soundly soundly between at least some feedings? *
Does your baby wake up to nurse on his/her own before three hours have past? *
If your baby is fussy, which are you more likely to do? *
What other than breast and breastmilk have you put in your baby's mouth? *
ie, pacifiers, expressed breastmilk in a bottle, water, forumla, etc, including what may have given to them in the hospital.
Your answer
Thinking back to yesterday and/or last 24 hours, please detail your day with the baby. *
ie baby nursed at 6am, 8:30am, etc.
Your answer
Questions about Mom
Do you use a nipple sheild? *
If you use a nipple shield, why? Did someone recommend it, who, and is it helping?
Your answer
Do you nurse the baby during the night *
Compare nightime feedings to daytime. Is one better than the other? About the same? *
When the baby is nursing, do you hear him/her swallowing? *
What is the suck to swallow ratio? *
Two sucks to every swallow/pause (2:1)? 1:1, 3;1, 10:1, etc? If not sure, write not sure.
Your answer
What day did your milk come in? *
Have your breasts felt full? *
Postpartum Bleeding? *
Your bleeding will be heavy at first, but it should be decreasing daily. Continued heavy flow past the first day may indicate a problem such as retained placenta, or maybe you are just doing too much. See your doctor or midwife to evaluate your bleeding if it is heavy and bright.
Are your breasts symmetrical or asymmetrical? *
Is one the same size/shape as the other, or are they different from the other?
Was this pregnancy sponteneous or did you use fertility treatments? If the latter, please describe. *
Spontaneous pregnancy means no fertility treaments.
Your answer
Have you had any surgeries and/or injuries including augmentation or reduction involving your breast(s)? If yes, what and when? Please describe procedures physical changes to your breasts to the best of your knowledge. *
Your answer
If you had any breast surgeries, what if anything did the surgeon say how it could affect your future breastfeeding?
Your answer
Where you a premature baby that needed intubation? (weird question, right? it's amazing how many variables can affect nursing) *
Do you or did you during this pregnancy; smoke, drink alcohol and/or use any other medications/drugs including prescription, OTC, and/or elicit street drugs? *
If yes, please detail which, how much and with what frequency.
Your answer
Have you had your thyroid checked in the six months? *
If yes, what were the findings?
Your answer
Are you feeling?
Are you now, or have you ever been concerned about your weight and been anorexic, bulemic, or another eating disorder?
How often do you think a newborn baby should nurse? *
How often do you nurse and/or attempt to nurse your newborn? *
Did your breasts change during pregnancy *
Swelling, tenderness, etc
Are you using a breastpump? If yes, how is it working out? *
Your answer
Which make/model pump? Is it manual or electric?
Your answer
If you started pumping, when and why did you start pumping?
Your answer
What is your current pumping schedule and yield? Why did you choose this current pumping schedule?
Your answer
If you are pumping, how much milk do you get from pumping? How much of that milk do you feed to the baby and how often?
Your answer
Are you supplementing the baby's diet with formula and/or donated breastmilk? If yes, how much how often?
Your answer
While breastfeeding...
You and your partner can work on filling this out, or I may fill it out if I am observing a feeding. It is normal for you and your partner or other support person to have different answers. Both are correct.
Are you physically comfortable feeding your baby? *
Shoulders, back, neck, bottom, privacy, etc?
Is nursing painful? *
Nursing when done correctly isn't painful. Pain usually means the latch needs an adustment.
What, if anything, have you already tried to remedy any sypmtoms you may have had from the above question?
Your answer
Is the baby's mouth wide open and gaping as he/she latches on to the breast? *
Is the baby's mouth well up on the areola? *
We don't want to aim the baby's mouth like a bulls eye onto the breast. We want the nipple to go into the mouth high, above the tongue, toward the back of the throught.
While nursing, does the baby's nose touch the breast? *
While nursing, is the babies tongue coming out over the lower gum? *
Are mom and baby tummy to tummy with the baby facing the boob and the body aligned? *
Is the baby taking in a good mouthful of breast? *
Wait until the baby's mouth is wide and gaping open, and their head tilted back, then while gently holding the back of their neck, push them onto the breast, chin and bottom lip first.
Can you hear the baby swallowing regularly? *
Your answer
Is the baby able to maintain suction? *
Day 3 or later once your milk comes in; Can you feel the milk let down when you nurse? *
Once latched, does the baby nurse vigourously? *
Does the baby protest and become upset when the milk lets down? *
What else do I need to know about your nursing and lifestyle to assess your baby and breastfeeding?
Your answer
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