Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Support Person

First Name

Last Name

Phone

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Due Date

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DD

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Doctors Name

First Name

Last Name

As long as the baby and I are healthy, I would like to wait until 41 weeks before inducing labor.

As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy.

I would like to discuss laboring at home as long as possible.

I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan.

If nonstress test observation becomes necessary after my due date, I am flexible and support this procedure.

I would like to discuss induction before I reach my due date.

If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced.

Please obtain my permission before stripping my membranes during a vaginal exam.

I prefer to have no vaginal exams until I go into labor.

I prefer to have only one vaginal exam on or around my due date.

During a vaginal exam, I prefer not to have my membranes broken unless there is an emergency situation.

I prefer minimal internal vaginal exams

If I am less than four centimeters dilated, I would like to discuss with my healthcare provider the option of going home.

After medical guidance related to pain relief, I would like privacy with my partner to discuss which pain management technique or medication I prefer.

Please suggest pain management options if you notice that I am experiencing extreme discomfort.

Please discuss pain management options as soon as possible.

After medical guidance related to pain relief, I would like privacy with my partner to discuss which pain management technique or medication I prefer.

Ideally I prefer to move around as I wish during labor and delivery.

I prefer to be unrestricted in accessing any sounds such as moaning, grunting, and or yelling.

Please keep door closed for duration of labor and delivery.

AROM (artificial rupture of membranes)

Foley/ cooks catheter

Cytotec (not compatible with VBAC)

Cervidill

Prostaglandin

Pitocin

Forceps

Vacuum

Episiotomy

Contraction and heart rate monitors

Oxygen

IV Fluids

Hep Lock

Antibiotics

Blood Transfusion

None

Handheld Doppler

Intermittent

Continuous

Internal (fetal scalp) wireless

Breathing techniques

Massage

Visual imaging work

Distraction techniques

Acupressure

Deep or guided meditation/ relaxation

Hypnobirthing

I prefer to have my primary support person with me at all times

Music

Dim Lighting

Aromatherapy

Wear my own clothes

Students allowed

Students not allowed in

Quiet voices/ minimal distraction

Birthing Room

Room with a shower and/or bath

Delivery room

Home

Birthing bed

Birthing ball

Birthing tub/ pool/ shower

Birthing stool

Squatting bar

I would like no one to speak during actual delivery.

I want to wear hospital clothing.

I would like for there to be a tv available.

I would like to wear headphones during my labor and delivery.

I would like my birth photographed.

I would like to wear my contacts and/or glasses unless removal medically necessary.

Hydrotherapy (tub/ shower)

Hot/ cold packs

Massage

Counterpressure

Nitrous Oxide

IV pain meds (narcotic)

Sterile Water Injections

Epidural

Only offered when asked for

Offered free throughout labor

Drinking/ eating

Ice chips

IV fluids

Sucker/ honey stick/ popsicle, etc.

As long as baby and I are healthy I do not want a time restriction on pushing.

Toilet (forwards/ backwards)

Ball (rocking/ rolling/ hip circles)

Lunging

Standing

Laying down (side/back)

Dancing/ swaying

Squatting

Hands and knees

Birth stool

I will ask for an enema if I feel I need one.

Whatever feels right in my body at the time.

Encourage me to breathe properly for slower crowning.

Please use a local anesthetic for repairs.

No stirrups unless it is a medical emergency.

Directed

Spontaneous with the urge

Counting

Holding breath

Breathing baby down

Labor down

Side Lying

Hands and knees

Squatting

Tug of war

In water

Lying on back

Perineal support

Perineal stretching

Warm Compresses

Mineral oil

Episiotomy

Prefer to tear

Mirror to watch

Touch head when crowning

I would like to catch my baby and allow them to rest on my abdomen as it is born.

I would like my partner to catch my baby.

I would like the doctor to catch my baby.

For spiritual or religious purposes I would like the room to be totally silent when the baby is born.

Delayed cord clamping

Immediate cord clamping

Cord clamping done by me or primary support person

Lotus birth ( placenta delivered attached to baby)

Pitocin to expel placenta/ control bleeding ( IV or IM)

Natural expulsion of placenta (no Pitocin/ wait and see approach)

Fundal Massage

Skin to skin immediately

Weight/ measurement immediately

Suction babies mouth and throat

Deny suction

Keep placenta (personal/ encapsulation)

To be offered a room at the hospital for the duration of my baby's stay (within reason).

Golden hour

All assessments on birthing body

All assessments at warmer

No separation unless my baby is sick

Transported with my baby if possible

I would like the nursery to fully care for my baby and bring them to me for feedings.

Delayed rooming until I have had time to rest

Erythromycin eye cream (immediate or delayed)

I prefer any immunizations to be postponed to later time

Hepatitis B Vaccine (immediate or delayed)

Vitamin K injection or sublingual

Primary support person to be with baby if I cannot

Primary support person stay with me at all times

Bath asap

Bath delayed/ denied

Skin to skin with birthing body, parent, or primary support person

Breast/ Chestfeed

To breastfeed or express my milk for baby

Formula

Please offer guidance on the issue of formula versus breasfeeding.

Bottle feed

I would like to combine breastfeeding and bottle feeding.

Pacifier

Immunize baby according to normal procedures

I would like to bathe my baby with my own products.

Please do not circumcise my baby.

Please do not retract my son's foreskin.

Please use a local anesthetic.

Please delay procedure as long as possible.

Please do routine PKU testing after 24 hrs.

I would like to wait and delay the PKU testing until we are ready to leave the hospital.

Artificial nipples

Sugar water

Spinal anesthesia

General anesthesia

Primary support/ doula/ photographer present

Photographs

No small talk

Music

Clear Drape

Drop drape/ watch birth

Mirror to watch birth

Bed angled for better view of birth

Slow/ gentle delivery

Delayed cord clamping

One arm free

Nausea meds or none

Vaginal seeding

Breastfeed in OR

Breastfeeding in recovery

Skin to skin in OR

Skin to skin in recovery

Primary support skin to skin in OR

Primary skin to skin in recovery

Blood transfusion

Iron Supplements