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Birth Preference Worksheet
* indicates required field
Name
*Name
Due Date
clear
* Due Date
Email Address
*Email Address
Partner's Name
Partner's Name
Doctor's Name
*Doctor's Name
Hospital Name
*Hospital Name
Please note that I have
Please note that I have
Group B Strep
Group B Strep
Gestational Diabetes
Gestational Diabetes
Other
Other
My delivery is planned as
Select My delivery is planned as
Vaginal
C-Section
Water Birth
VBAC
Home Birth
* My delivery is planned as
I’d like the following people for my birth
Partner (listed)
Partner (listed)
Partner Visitation
Before
During
After
Partner Visitation
Parents (listed)
Parents (listed)
Parents Visitation
Before
During
After
Parents Visitation
Other Kids (listed)
Other Kids (listed)
Other Kids Visitation
Before
During
After
Other Kids Visitation
Other (listed)
Other (listed)
Other Visitation
Before
During
After
Other Visitation
* During labor I would like
During labor I would like
Music played (I will provide)
Music played (I will provide)
To wear my own clothes
To wear my own clothes
Stay hydrated with clear liquids/ice chips
Stay hydrated with clear liquids/ice chips
To wear my contact lenses
To wear my contact lenses
Eat/drink as approved by doctor
Eat/drink as approved by doctor
My partner to film/take pictures
My partner to film/take pictures
My partner to be present entire time
My partner to be present entire time
Lights dimmed
Lights dimmed
Room quiet as possible
Room quiet as possible
Few interruptions as possible
Few interruptions as possible
Few vaginal exams as possible
Few vaginal exams as possible
Hospital staff limited to my own doctor and nurses (no students or residents or interns present)
Hospital staff limited to my own doctor and nurses (no students or residents or interns present)
* I’d like fetal monitoring to be
I’d like fetal monitoring to be
Continuous
Continuous
Intermittent
Intermittent
Internal
Internal
External
External
Performed only by doppler
Performed only by doppler
Performed only if the baby is in distress
Performed only if the baby is in distress
I’d like to progress my labor if
Select I’d like to progress my labor if
Performed only if baby is in distress
First attempted by natural methods (such as nipple stimulation)
Performed by membrane stripping
Performed with Pitocin
Performed by rupture of the membrane
Never to include an artificial rupture of the membranes
* I’d like to progress my labor if
I’d like to spend the first stage of labor
Select I’d like to spend the first stage of labor
Standing Up
Lying Down
Walking Around
In the Shower
In the bathtub
* I’d like to spend the first stage of labor
* For pain relief I’d like to use
For pain relief I’d like to use
Breathing Techniques
Breathing Techniques
Cold Therapy
Cold Therapy
Distraction
Distraction
Hot Therapy
Hot Therapy
Massage
Massage
Standard Epidural
Standard Epidural
Nothing
Nothing
Only what I request at the time
Only what I request at the time
Whatever is suggested at the time
Whatever is suggested at the time
* During delivery I would like to
During delivery I would like to
Squat
Squat
Semi - recline
Semi - recline
Lie on my side
Lie on my side
Lean on my partner
Lean on my partner
Be on my hands & knees
Be on my hands & knees
Stand
Stand
Use people for leg support
Use people for leg support
Use foot pedals for support
Use foot pedals for support
Use birth bar for support
Use birth bar for support
Use a birthing stool
Use a birthing stool
Be in a birthing tub
Be in a birthing tub
Be in the shower
Be in the shower
* As the baby is delivered, I would like to
As the baby is delivered, I would like to
Avoid forceps usage
Avoid forceps usage
Avoid vacuum extraction
Avoid vacuum extraction
Use whatever methods my doctors deems necessary
Use whatever methods my doctors deems necessary
Help catch the baby
Help catch the baby
Let my partner catch the baby
Let my partner catch the baby
Push spontaneously
Push spontaneously
Push as directed
Push as directed
Push without time limits as long as baby and I are not at risk
Push without time limits as long as baby and I are not at risk
Use mirror to see the baby crown
Use mirror to see the baby crown
Touch the head as it crowns
Touch the head as it crowns
Let the epidural wear off while pushing
Let the epidural wear off while pushing
Have a full dose of epidural
Have a full dose of epidural
* I would like an episiotomy
I would like an episiotomy
Only after perineal massage
Only after perineal massage
warm compresses and positioning
warm compresses and positioning
Rather than risk a tear
Rather than risk a tear
Not performed
Not performed
even if it means risking a tear
even if it means risking a tear
Performed only as a last resort
Performed only as a last resort
* Immediately after delivery, I would like
Immediately after delivery, I would like
My partner to cut the umbilical cord
My partner to cut the umbilical cord
The umbilical cord to be cut only after it stops pulsating
The umbilical cord to be cut only after it stops pulsating
To deliver the placenta spontaneously
To deliver the placenta spontaneously
To see the placenta before it is discarded
To see the placenta before it is discarded
Not be given pitocin/oxytocin
Not be given pitocin/oxytocin
* If a c-section is necessary, I would like
If a c-section is necessary, I would like
For baby to have skin to skin before examination
For baby to have skin to skin before examination
To make sure all other options have been exhausted
To make sure all other options have been exhausted
To stay conscious
To stay conscious
My partner to remain with me the entire time
My partner to remain with me the entire time
The screen lowered so I can watch the baby come out
The screen lowered so I can watch the baby come out
My hands left free so I can touch the baby
My hands left free so I can touch the baby
The surgery explained as it happens
The surgery explained as it happens
An epidural for anesthesia
An epidural for anesthesia
My partner to hold the baby as soon as possible
My partner to hold the baby as soon as possible
To breastfeed in the recovery room
To breastfeed in the recovery room
I would like to hold baby
Select I would like to hold baby
Immediate after delivery
After suctioning
After weighing
After being wiped clean and swaddled
Before eye drops/ointment are given
* I would like to hold baby
I would like to breastfeed
Select I would like to breastfeed
As soon as possible after delivery
Later
Never
* I would like to breastfeed
* I would like the baby's medical exam and procedure
I would like the baby's medical exam and procedure
Given in my presence
Given in my presence
Given only after we've bonded
Given only after we've bonded
Given in my partner's presence
Given in my partner's presence
Include heel stick for screenings beyond the PKU
Include heel stick for screenings beyond the PKU
To include a hearing screening test
To include a hearing screening test
To include a hepatitis B vaccine
To include a hepatitis B vaccine
* Please don't give baby
Please don't give baby
Vitamin K
Vitamin K
Antibiotic eye treatment
Antibiotic eye treatment
Sugar Water
Sugar Water
Formula
Formula
A pacifier
A pacifier
* I’d like baby's first bath given
I’d like baby's first bath given
In my presence
In my presence
In my partner's presence
In my partner's presence
By me
By me
By my partner
By my partner
No bath at all
No bath at all
* I'd like to feed baby
I'd like to feed baby
Only with breastmilk
Only with breastmilk
Only with formula
Only with formula
On demand
On demand
On schedule
On schedule
With the help of a lactation specialist
With the help of a lactation specialist
I'd like my baby
Select I'd like my baby
To be wiped off after birth
Left alone to keep vernix on
* I'd like my baby
* I'd like my partner
I'd like my partner
To have unlimited visiting
To have unlimited visiting
To sleep in my room
To sleep in my room
If we have a boy, a circumcision should
Select If we have a boy, a circumcision should
Be performed
Not be performed
Be performed later
* If we have a boy, a circumcision should
* As needed post delivery, please give me
As needed post delivery, please give me
Extra strength acetaminophen
Extra strength acetaminophen
Percocet
Percocet
Stool softener
Stool softener
Laxative
Laxative
Family/friends not named to be able to
Select Family/friends not named to be able to
To join us after delivery
To join us in the room later
To have unlimited visiting after birth
* Family/friends not named to be able to
* If baby is not well, I'd like
If baby is not well, I'd like
To accompany baby to NICU/other facility
To accompany baby to NICU/other facility
To breastfeed/provide pumped breastmilk
To breastfeed/provide pumped breastmilk
To hold him or her whenever possible
To hold him or her whenever possible
After birth, I'd like to stay in the hospital
Select After birth, I'd like to stay in the hospital
As long as possible
As briefly as possible
* After birth, I'd like to stay in the hospital
Other Notes
Other Notes
Signature
*Signature
Date
*Date
Submit
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