Download FormWhile birth can sometimes be unpredictable, working through your birth preferences can help decrease anxiety and improve your overall birth experience. Please print this form, complete and bring to a visit with you during your third trimester.
Before Labor Begins
- I would like to wait as long as possible for natural labor (41 weeks and 5 days for mothers without a medical indication for induction)
- I would like to be induced at 41 weeks
- I would like an elective induction between 39 and 41 weeks if my cervical exam qualifies me for such
- I would like my membranes stripped when possible (after 39 weeks)
- I would like to use natural cervical ripening methods like nipple stimulation, Evening Primrose oil and raspberry leaf tea after 36 weeks
Hospital Clothing
- Hospital gown
- My own clothing
Baby Monitoring
- Continuous
- Wireless
- Intermittent
- Internal
Pain Relief Measures
- Offer it to me
- Only if I ask for it
- Offer it to me
- Only if I ask for it
Relaxation Techniques
- Vocalization
- Relaxation
- Breathing
- Imagery/Visualization
- Focal Point
- Massage
Comfort Measures
- Hot/cold packs
- Massage
- Aromatherapy
- Low lighting
- Doula support
- Shower/tub (where available)
- Music
Hydration
- Drink clear fluids
- IV fluids
Food
- Eat lightly at home
- Water/juice/jello/popsicles
- Nothing to eat
Positions
- Walking
- Sitting
- Lying down
- Rocking
- Standing
- Hands and knees
- Squatting
- Lunging
- Birth ball
Augmenting Labor
- Patience/nothing
- Nipple Stimulation
- Position changes
- Releasing of water
- Pitocin
Pushing
- Spontaneous
- Directed/coached
- Varying positions
- Mirror present
Perineal Care
- Perineal massage
- Warm compress
- Slow delivery of head
- Episiotomy (not standard)
Delivery Position
- Semi-sitting
- Side lying
- Hand and knees
- Squatting
Cutting Cord
- Partner or mother
- Doctor/midwife
- Wait until cord stops pulsating (delayed cord clamping)
- Cut as soon as possible
- Cord blood banking planned
After Delivery
- Baby skin to skin with mother
- Baby to be taking directly to the warmer
- Clean baby before holding
- Delay baby’s bath for at least 24 hours
- Baby stays in the room
Placenta
- Per hospital protocol
- Encapsulation planned
Newborn Medications
- Antibiotic eye ointment
- Hepatitis B vaccine
- Vitamin K injection (required for circumcision; oral is not a reasonable substitution)
Circumcision
- Give Tylenol
- Give Sweet-Ease
- Use Lidocaine or Marcaine
Feeding
- Breastfeeding only
- Formula feeding
- No pacifiers
- Pacifiers OK
- Breast pump if needed
- Lactation consultation
Twin Vaginal
- Partner present
- Doula present
- Dimmed lights
- Epidural
- Skin to skin between deliveries
Belly Birth
- Partner present
- Doula present
- Dimmed lights
- Clear drape at delivery
- Mom’s music playlist
- Take pictures
- Skin to skin as soon as possible