Birth Preferences

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Birth Preferences

Please review the following birth preferences to help guide you in making decisions for your birth and creating a “birth plan”

Mother’s Support Team who will attend birth:

_________________________________________________ ____________________________________________

_________________________________________________ ____________________________________________
_________________________________________________ ____________________________________________
Before Labor Begins:

  • As long as baby and I are healthy, I would like to go at least _______ days past my due date before inducing labor

  • I wish to labor at home for as long as possible

  • I would like to discuss the option of induction before I reach my due date

Vaginal Exams:

  • Please DO NOT strip my membranes during a vaginal exam unless:

    • You obtain my permission prior

    • There is an emergency situation

  • I prefer no vaginal exams until:

    • My due date

    • I go into labor

    • I have the urge to push

Hospital/Birth Place Admittance:

  • I would like the option of staying in the hospital regardless of my dilation

  • If I am less than 4 centimeters dilated, I would like to discuss the option of going home


Natural induction techniques I would like to try:

  • Acupuncture/Acupressure

  • Nipple stimulation

  • Walking

  • Guided positions

  • Sexual intercourse

  • Herbs

  • Caster oil

Medical Induction (if medical necessary):

  • Stripping membranes

  • Rupturing membranes

  • Prostaglandin gels

  • Pitocin

If my membranes repture before I go into labor, I would like to:

  • Please wait __________ hours before being induced, as long as baby and I are healthy


I prefer to give birth:

  • In a birthing room

  • A room with a shower and/or bath

  • Delivery room

  • At home

Equipment I would like to use (if available)

  • Birthing bed

  • Birthing ball

  • Bean bag chair

  • Birth tub/pool/shower

  • Squatting bar

Other requests (if available)

  • Dimmed lights

  • Door closed

  • Soft speaking/quiet voices

  • Wearing my own clothes

  • Having a TV available

  • Having a DVD available

  • Music playing

    • I will provide my own music and equipment

  • Having my birth photographed or recorded

    • _________________________________________ (name) will be photographing/recording

  • I plan to wear

    • Glasses

    • Contacts

Pain Management:

  • Please only offer medications if I ask for them

  • After providing me with options, please allow private time to discuss with my partner

I would like to handle my pain with the following methods (un-medicated):

  • Breathing techniques

  • Distraction techniques

  • Hypnotherapy

  • Acupuncture/Acupressure

  • Massage

  • Visualization

  • Bath/shower

  • Chanting, grunting, or moaning

I would like to use the following medications:

  • Walking epidural

  • Classic epidural

  • Sedative

  • Tranquilizer

  • Narcotics


I prefer the baby be monitored with:

Active Labor

I have prepared with the following:

  • Lamaze Techniques

  • Bradley Techniques

  • Childbirth Hypnosis

  • Natural childbirth instruction

I would like to use the following positions:

  • Squatting

  • Hands and knees

  • On the toilet

  • Standing upright

  • Classic semi-recline

  • Side lying

  • Other guided positions


  • Please only offer me an enema if I ask for one

  • I would like to have an enema upon being admitted


  • I prefer to have no episiotomy and accept the risk of tearing

  • If I need an episiotomy, I prefer a pressure episiotomy

  • I would like my care giver to preform an episiotomy

To help prevent tearing:

  • Apply hot compresses

  • Apply oil

    • I will provide

  • Use perineal massage

  • Encourage me to breathe properly for slower crowning

Other labor requests:

  • Please allow the shoulders and body of my baby to be born spontaneously, on their own

  • Please use a local anesthetic for repairs

  • Please do not use stirrups unless I am having a medical emergency


The delivery:

  • I would like to use a mirror

  • I would like to touch my baby’s head as it crowns

  • I would like to catch my baby and pull it onto my abdomen

  • I would like my partner to catch the baby

  • For spiritual reasons, I would like the room completely silent as the baby is born


  • Unless an emergency, please give my partner an me time to think about the decision before we give consent

  • Please discuss my post-operative pain medication options immediately following the procedure

  • My partner is to be present at all times during the procedure

  • I would like to discuss anesthesia options before they are administered

  • I prefer a low transverse incision on my abdomen and uterus

  • I would like the operating room quiet

  • I would like baby:

    • To be shown to me after it is born

    • To have contact with me as soon as it is born

    • To be held by my partner as soon as it is born

    • To not be bathed

  • Please let my partner cut the corn

  • I would like one hand free for the option to touch the baby

  • I would like the process filmed/photographed as the baby comes out

  • I would like the following people in the operating room:

    • __________________________________________

    • __________________________________________

    • __________________________________________


As long as my baby is healthy

  • I would like to nurse immediately in recovery

  • Please do not administer Pitocen unless there is a medical need

  • I would like my partner to be in constant contact with the baby until I am free to hold it

  • I would like my baby sent to the nursery while I am in recovery

  • I would like my catheter and IV removed immediately after my recovery period

  • Please discuss what to expect immediately following the procedure

  • Please discuss my post operative pain management options immediately following the procedure

After the baby is born:

Umbilical Cord:

  • Please wait for the umbilical cord to stop pulsating before it is clamped (appx. 5 minutes)

  • Please allow my partner to cut the umbilical cord

  • I have made arrangements to bank my baby’s cord blood


  • I would prefer the placenta to be born spontaneously without the use of Pitocin

  • I would like to take the placenta home with me

Newborn Procedures:

As long as baby is healthy:

  • Immediately skin-to-skin on my abdomen with a warm blanket

  • Please allow my baby to successfully breastfeed before:

    • Routine medications

    • Anything that is not medically necessary

  • I would like all newborn procedures performed in my presence

  • I would like all newborn procedures performed immediately

Eye ointment:

  • I would like eye ointment administered immediately after birth

  • I would like to delay administration of eye ointment

  • I wish to sign a wavier to decline eye ointment

Vitamin K:

  • I would like my baby to receive vitamin K immediately after delivery

  • I would like to delay vitamin K injections until after breastfeeding and bonding

  • I would like oral administration of vitamin K

  • I wish to sign a wavier to decline vitamin K injections


  • I prefer immunizations to be postponed

  • I prefer only ____________________________________________________ to be given after birth

  • Please immunize my baby according to normal procedures

  • I wish to sign a wavier to decline all immunizations


  • Do not circumcise

  • I would like my baby circumcised:

    • With a local anesthetic

    • Please wait until after breastfeeding and bonding


  • Please do a routine PKU testing after 24 hours

  • I would like to delay PKU testing until before discharge

  • I decline PKU testing at the hospital and having made other arrangements for a later date


  • I will exclusively breastfeed

  • I will exclusively formula feed

  • I wish to combine formula and breastfeeding

  • I would like to see a lactation consultant for recommendations and guidance

  • Please do not give my baby any of the following without consent:

    • Formula

    • Pacifiers

    • Artificial nipple

    • Sugar water

Bathing Baby:

  • Please bathe my baby after breastfeeding and bonding

  • Please do not bathe my baby at all

  • I will provide products to bathe baby

In an emergency relating to the baby, I wish:

  • To be transported with my baby

  • My partner to be with my baby

  • To express milk for my baby

  • To have as much bodily contact as possible with my baby

  • To be offered a room at the hospital for the duration of my baby’s stay

In-hospital routine:

  • Full rooming in

  • Delayed rooming in, until I have rested

  • Partial rooming in, I prefer the baby in the nursery at night so I can rest

  • Nursery care: I would like the nursery to fully care for my baby and bring it to me for feedings

My hospital stay:

  • I prefer my hospital stay:

    • Be as short as possible

    • Be as long as possible

    • In a private room

  • I prefer my partner stay with me

  • I would like my children to be allowed to visit with me as long as they wish

  • I would like my guests to be allowed to visit me for as long as they wish

  • I want my guests to have a limited time to visit

  • I want privacy during my stay and do not want visitors

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