My Personal Preferences
Environment
Private birthing room
Dim lights
Peace and quiet
Bring our own music
Wear my own clothes
Private phone
We would like to video labor and birth
We would like to take pictures during labor and birth
No unnecessary exams or visits by students, residents, etc.
Minimal vaginal exams (vaginal exams can actually cause problems such as infection
and premature rupture of membranes)
Other (Please Specify)
Procedures and Labor:
Free to walk around and go to the bathroom throughout labor
Freedom to move in bed only (and to use the bathroom)
Mobility not important (catheter, regular epidural)
I would prefer to avoid an enema and/or shaving of pubic hair
I would like to be able to eat and drink whatever I want
I would like to be free to drink clear fluids
I would like ice chips available to me at all times
Heparin/Saline lock (Most hospitals require this as access to a vein should an emergency
occur, it can also be used in place of an IV for administration of antibiotics for
complications such as MVP or Beta Strep)
I do not want an IV unless I become dehydrated
I would like to choose my positions for pushing and giving birth
Monitoring:
I do not wish to have continuous fetal monitoring unless it is required by the condition
of the baby
I do not want an internal monitor unless the baby has shown some sign of distress
I prefer fetal monitoring
In the event that I require or have chosen fetal monitoring, my preference is:
Pain Relief Options
I plan to give birth naturally without medication and will be coping with pain using
the following techniquesCheck this option then click here to continue
I am attempting a natural childbirth but if I ask for pain medication I'd like to
useCheck this option then click here to continue
Please administer pain medication as soon as possibleCheck this option then click here to continue
Choose options here if you checked the first option:
(Choose as many as you wish.)
Bradley Method
Lamaze
Water (shower or tub)
The Alexander Technique
Massage
Acupressure
Other, please state:
Select one or more of the following if you've chosen option 2 or 3 .
Stadol
Walking epidural (low dose)
Epidural block
Other
Induction/Augmentation
Check here if you want induction/augmentation preferences included in your birth
plan
Upon agreeing to an induced labor you will reduce some of your birth options, but
preparing a birth plan and discussing your expectations and preferences with your
primary caregiver is recommended. Please note, there are some natural methods for
inducing labor we are not listing here. You may wish to try these before choosing
a hospital induction.
do not wish to have the amniotic membrane ruptured artificially unless their are
signs of fetal distress
If labor is not progressing, I would like to have the amniotic membrane ruptured
before other methods are used to augment labor
I would prefer to be allowed to try changing position and other natural methods
before medical methods or medications are used
If you choose to be induced or it becomes medically necessary please state your
preferences:
Complications and Cesareans
Check here if you want complications and Cesareans preferences included in your
birth plan.
Unless absolutely necessary, I would like to avoid a Cesarean
If my primary caregiver recommends a Cesarean birth, I would like a second opinion
if time warrants
If my primary physician recommends a Cesarean, I accept and will cooperate with
the procedure at any time
Normal Childbirth (Vaginal Delivery)
Check here if you want normal childbirth (vaginal delivery) preferences included
in your birth plan.
I would like a mirror available so I can see the baby's head when it crowns
I would like to have the baby placed on my stomach/chest immediately after delivery
I would like to try to deliver in a hands-and-knees position
Please dim the lights for the birth
I would appreciate having the room as quiet as possible when the baby is born
I want an injection of Pitocin after the delivery to aid in expelling the placenta
I do not want a injection of Pitocin after the delivery to aid in expelling the
placenta
I would like to see the placenta after it is delivered
Prefer no episiotomy (massage, compresses, positioning, etc.) Select this one if
you would prefer no episiotomy but not to the point of tearing.
Prefer to tear (massage, compresses, positioning, etc.) Select this option if you
would prefer to tear rather than have an episiotomy.
Episiotomy
Pressure episiotomy (Done without anesthesia, although you cannot feel it due to
the pressure from the baby's head.)
Local anesthesia (for repair)
Cesarean Delivery
Check here if you want Cesarean preferences included in your birth plan.
If you're scheduled for a Cesarean birth or if it becomes medically necessary
for the health of you or your baby, please state your preferences.
Spinal/epidural anesthesia
General anesthesia
I would like my partner or coach present
I would like my partner to be able to take video/pictures
Screen lowered to view birth
Touch the baby as soon as possible
Partner to cut cord
Other (Please specify):
Baby Care
Check here if you want baby care preferences included in your birth plan.
Umbilical Cord:
Partner would like to cut cord
I would like to cut the cord
Neither of us wishes to cut the cord
Eye Care:
None
Delayed for bonding time
Immediate
Feeding Baby:
Breastfeeding only
Bottle feeding only
Combination
No pacifiers or glucose water (To avoid nipple confusion.)
Separation:
No separation: baby/mother rooming in
Delayed (after recovery period)
Partial rooming-in (baby with mother during day, but not night)
Nursery (baby brought to you on your schedule)
Circumcision:
In the hospital
Parents present
Use anesthesia (depends on the practitioner)
None (Check here if you do not intend to have the baby circumcised, or if you do
not intend to have him circumcised at the birth place.)
Do not retract the foreskin
Sick Infant:
Breastfeeding, if possible
Unlimited visitation for parents
Handling the baby (holding, care of, etc.)
If baby is transported to another facility, move us as soon as possible
Other (Please specify):
