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Personal Details
First Name:
Surname:
Partners Name:
Primary Healthcare provider:
Hospital / Birth Center:
Due Date:
Labor
- I would prefer to avoid an enema and/or shaving of pubic hair
- I would like to be free to walk around during labor
- I wish to be able to move around and change position all throughout labor
- I would like to be able to have fluids by mouth throughout the first stage of labor
- I will be bringing my own music to play during labor
- I would like the environment to be kept as quiet as possible
- I would like the lights in the room to be kept low during my labor
- I would prefer to keep the number of vaginal exams to a minimum
- I do not want an IV unless I become dehydrated
- I would like to wear contact lenses or glasses at all times when conscious Other:
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 Other:
Labor Augmentation / Induction
- I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring
- 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 positions and other natural methods (walking, nipple stimulation) before pitocin is administered Other:
Anaesthesia / Pain Medication
- I realize that many pain medications exist — I’ll ask for them if I need them Before considering an epidural, and if the situation warrants,
- I would like to try an injection of narcotic pain relief (Nubain, Demerol, Stadol or similar)
- I would like to have a standard epidural
- I would like to have a walking epidural (low dose) Other:
Cesarean
- Unless absolutely necessary, I would like to avoid a Cesarean
- If my primary care giver determines that a Cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows
- If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making processes
- I would like __________ (coach) present at all times if the baby requires a Cesarean delivery
- I wish to have an epidural for anaesthesia
- So I can view the birth, I would like the screen lowered just before delivery of the baby
- If the baby is not in distress, the baby should be given to ___________ (coach) immediately after birth Other:
Episiotomy
- I would prefer not to have an episiotomy unless absolutely required for the baby’s safety
- I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage
- I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch
- If possible, I would like to use perineal massage to help avoid the need for an episiotomy
- I would prefer an episiotomy rather than a tear
- I would like a local anesthetic to repair a tear or an episiotomy Other:
Delivery
- I would like to be allowed to choose the position in which I give birth, including squatting
- I would like __________ (partner) and/or nurses to support me and my legs as necessary during the pushing stage
- I would like to try to deliver in a hands-and-knees position
- I would like to try to deliver in a squatting position, using __________ (coach) or a squatting bar for support
- I would like a mirror available so I can see the baby’s head when it crowns
- I would like the chance to touch the baby’s head when it crowns
- Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase
- I would appreciate having the room lights turned low for the actual delivery
- I would appreciate having the room as quiet as possible when the baby is born
- I would like to have the baby placed on my stomach/chest immediately after delivery Other:
Immediatly After The Delivery
- I would like to have my partner cut the cord.
- I would like to cut the cord myself
- I would prefer that the umbilical cord stop pulsating before it is cut
- I would like to hold the baby while I deliver the placenta and any tissue repairs that are made
- I would like to hold the baby for at least fifteen minutes before (he/she) is photographed, examined, etc.
- I would like to have the baby evaluated and bathed in my presence I plan to keep the baby near me following birth and would
- appreciate if the evaluation of the baby can be done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation If the baby must be taken from me to receive medical
- treatment, __________ (coach) or some other person I designate will accompany the baby at all times
- I would prefer to hold the baby rather than have (him/her) placed under heat lamps
- I do not want a routine injection of pitocin after the delivery to aid in expelling the placenta
- I would like to delay the eye medication for the baby until a couple hours after birth
- After the birth, I would prefer to be given a few moments of privacy to urinate on my own before being catheterized
- I would like to donate the umbilical cord blood if possible
- I would like to bank the umbilical cord blood, and have made arrangements to do so
- I would like to see the placenta after it is delivered Other:
Postpartum
- I would like a private room, if available
- Unless required for health reasons, I do not wish to be separated from my baby
- I would like to have the baby “room in” and be with me at all times
- I would like to have the baby “room in” after I have had some time to recover
- I would like the baby with me during the day but in the nursery at night
- I would like the baby with me during the day but in the nursery at night, but brought to me for breastfeeding
- I would prefer the baby be kept in the nursery and brought to me upon request
- I would prefer the baby be kept in the nursery and brought to me upon request and for breastfeeding Other:
Breastfeeding
- I plan to breastfeed the baby and would like to begin nursing very shortly after birth Unless medically necessary, I do not wish to have any
- bottles given to the baby (including glucose water or plain water)
- I do not want the baby to be given a pacifier
- I do not plan to breastfeed the baby
- I would like more information about breastfeeding
- I would like to meet with a Lactation Consultant Other:
Circumcision
- I do not want the baby circumcised
- I do not wish to have the circumcision performed in the hospital
- I would like the baby to be circumcised before we check out of the hospital Other:
Photo / Video
- I would like to take still photographs during labor and the birth
- I would like to make a video recording of labor and/or the birth Other:
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