These are indications/examples only.. feel free to do your own, or none at all..
Environment:
□ Private Birthing Room
□ Dim Lights
□ Peace and Quiet
□ Bring our own Music
□ Wear my own clothes
□ Private Phone
□ We would like to video labor and birth.
□ We would like to take pictures during labor and birth.
□ No unnecessary exams or visits by students, residents, etc.
□ Minimal vaginal exams
Procedures and Labor:
□ Free to walk around, go to the bathroom throughout labor.
□ Freedom to move in bed only (up to the bathroom)
□ Mobility not important (catheter, used with regular epidural)
□ I would prefer to avoid an enema and/or shaving of pubic hair.
□ I would like to be able to eat & drink whatever I want.
□ I would like to be free to drink clear fluids.
□ I would like Ice Chips available to me at all times.
□ I do not want an IV unless I become dehydrated.
□ I would like to choose my positions for pushing and giving birth:
□ Semi-reclining
□ Side-lying position
□ Squatting
□ Hands and knees
□ Whatever feels right at the time
□ As long as my baby and I are doing fine, I'd like the pushing stage to be allowed to progress free of stringent time limits
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.
□ I prefer fetal monitoring.
In the event that I require or have chosen fetal monitoring, my preference is:
□ Fetoscopy
□ Doppler ultrasound
□ External Electronic Monitor
□ Internal Electronic Monitor
Pain Relief Options:
□ I plan to give birth naturally without medication and will be coping with pain using the following techniques:
□ Bradley Method
□ Lamaze
□ Water (Shower or tub)
□ The Alexander Technique
□ Massage
□ Acupressure
□ Doula
□ Other, Please state:___________________
□ I am attempting a natural childbirth but if I ask for pain medication I'd like to use:
□ Stadol
□ Nubain
□ Demerol
□ Walking Epidural (low dose)
□ Epidural block
□ Please administer pain medication as soon as possible.
□ Stadol
□ Nubain
□ Demerol
□ Walking Epidural (low dose)
□ Epidural block
Induction:
□ I do not wish to have the amniotic membrane ruptured artificially unless their are signs of fetal distress.
□ 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 position and other natural methods before medical methods or medications are used.
If you choose to be induced or it becomes medically necessary please state your preferences:
□ Pitocin ®
□ Prostaglandin gel
□ Amniotomy
Complications & Cesareans
□ Unless absolutely necessary, I would like to avoid a Cesarean.
□ If my primary caregiver recommends a cesarean birth I would like a second opinion if time warrants.
□ If my primary physician recommends a Cesarean. I accept and will cooperate with the procedure at any time.
Normal Childbirth (vaginal delivery)
□ I would like a mirror available so I can see the baby's head when it crowns.
□ I would like to have the baby placed on my stomach/chest immediately after delivery.
□ I would like to try to deliver in a hands-and-knees position.
□ Please dim the lights for the birth
□ I would appreciate having the room as quiet as possible when the baby is born.
□ To hold my baby right away, putting off any procedures that aren't urgent
□ To breastfeed as soon as possible
Placenta
□ I want an injection of pitocin after the delivery to aid in expelling the placenta.
□ I do not want a injection of pitocin after the delivery to aid in expelling the placenta.
□ I would like to see the placenta after it is delivered.
Episiotomy
□ Prefer No Episiotomy (Massage, compresses, positioning, etc.) (Select this one if you would prefer no episiotomy but not to the point of tearing.)
□ Prefer to Tear (Massage, compresses, positioning, etc.) (Select this option if you would prefer to tear than have an episiotomy.)
□ Episiotomy
□ Pressure Episiotomy (Done without anesthesia, although you cannot feel it due to the pressure from the baby's head.)
□ Local Anesthesia (for repair)
Cesarean Delivery
□ Spinal/epidural anesthesia
□ General anesthesia
□ I would like my partner or coach present
□ I would like my partner to be able to take Video/Pictures
□ Screen lowered to view birth
□ Touch the baby as soon as possible
□ Partner to cut cord
□ Other (Please specify):
Baby Care
Umbilical Cord:
□ Partner would like to cut cord
□ I would like to cut the cord
□ Neither of us wishes to cut the cord
□ Don’t’cut the cord before it stops pulsating
Eye Care:
□ None
□ Delayed for bonding time
□ Immediate
Feeding Baby:
□ Breast feeding only
□ Bottle feeding only
□ Combination
□ No pacifiers or glucose water (This would be to avoid nipple confusion.)
Separation:
□ No separation. Baby/ Mother rooming in.
□ Delayed (after recovery period)
□ Partial Rooming-In (Baby with mother during day, but not night.)
□ Nursery (baby brought to you on your schedule.)
Circumcision:
□ In the Hospital
□ Parents Present
□ Use anesthesia (Depends on the practitioner)
□ None (Check here if you do not intend to have the baby circumcised, or if you do not intend to have him circumcised at the birth place.)
□ Do not retract the foreskin
Sick Infant:
□ Breast feeding as possible
□ Unlimited visitation for parents
□ Handling the baby (holding, care of, etc.)
□ If baby is transported to another facility, move us as soon as possible
