Check all that apply. Will be reviewed with you at your 34 or 36 week visit. Best completed after attending your childbirth preparation class. If something is not listed here that is important to you, write it in and add it to your final copy. Please make a final copy and email to [email protected] or bring to your visit. You should have three (3) hard copies to bring to the hospital with you.


NAME: ______________________________________________________________________


ATTENDANTS

I'd like the following people to be present during labor and/or birth:

Partner: __________________________________________________________

Relative/Friend:____________________________________________________

Doula: ____________________________________________________________


General

I'd like to:

• bring music
  
• dim the lights
  
• wear my own clothes during labor and delivery
  
• take pictures and/or video during labor and delivery
  
• to walk and move around as I choose

HOSPITAL ADMISSION

• I'd like the option of returning home if I'm not in active labor
  

Once I'm admitted, I'd like:

• my partner to be allowed to stay with me at all times
  
  
• my practitioner, nurse, and guests to be present and I
  
  
• am comfortable with residents and students being present
  
  
• am comfortable participating in the teaching environment of the hospital, but request only a single resident doctor be present at any one time in my labor room, except in the event of an emergency
  
  
• would prefer no residents, except in the event of an emergency
  
  
• would prefer no medical students

FOOD, DRINK, IV Fluids

• to eat if I wish to
  
  
• to try to stay hydrated by drinking clear fluids, rather than with IV fluids
  
  
• to have IV fluids
  
  
• to have a heparin or saline lock
  
  
• I refuse any IV, unless medically necessary, and am aware that this could delay interventions in the event of an emergency
  
  

FETAL MONITORING

• Continuous Fetal Monitoring
  
  
• Mobile Continuous Fetal Monitoring
  
  
• Intermittent Fetal Monitoring using both mobile and stationary
  
  

LABOR PROPS

If available, I'd like to try a:

• birthing stool (available only with doula services birth)
  
  
• birthing ball
  
  
• squatting bar
  
  
• birthing pool/tub ( Currently not available unless patient supplied and must be approved by hospital)
  
  

PAIN RELIEF

[ ] I am planning an unmedicated birth

I'd like to try the following non-medicinal pain-management techniques:

• acupressure
  
  
• bath/shower
  
  
• breathing techniques/distraction
  
  
• hot/cold therapy
  
  
• self-hypnosis/Hypnobirthing
  
  
• massage
  
  
• Please don't offer me pain medication. I'll request it if I need it.
  
  

If I decide I want medicinal pain relief, I'd prefer:

• regional analgesia (an epidural and/or spinal block)
  
  
• systemic medication
  
  

[ ] I am planning a medicated birth

I’d like to try the following medicinal pain relief

• Systemic medication
  
  
• Epidural
  
  
• Walking epidural
  
  

PUSHING

When it's time to birth my baby, I'd like to:

• do so instinctively
  
  
• be coached on when to push and for how long
  
  
• be allowed to progress free of stringent time limits as long as my baby and I are doing fine
  
  
• have my Doctor direct me alone
  
  

I'd like to try the following positions for pushing (and birth):

• semi-reclining
  
  
• side-lying position
  
  
• squatting
  
  
• hands and knees
  
  
• whatever feels right
  
  

VAGINAL BIRTH

During delivery, I'd like:

• to view the birth using a mirror
  
  
• to touch my baby's head as it crowns
  
  
• the room to be as quiet as possible
  
  
• to give birth without an episiotomy
  
  
• my partner or myself to help "catch" our baby
  
  

After birth, I'd like:

Infant care

• to hold my baby right away, putting off any procedures that aren't urgent
  
  
• Vitamin K to be given
  
  
• Vitamin K to be withheld (please discuss with your pediatrician prior to delivery)
  
  
• Eye ointment to be given
  
  
• Eye ointment to be withheld (please discuss with your pediatrician prior to delivery)
  
  
• Breastfeeding to begin as soon as possible
  
  

Personal care

• Pitocin given to prevent bleeding after placenta is delivered
  
  
• No Pitocin after I deliver the placenta unless medically necessary. I understand this may increase my risk of bleeding after delivery.
  
  
• Wait until the umbilical cord stops pulsating before it's clamped and cut
  
  
• My partner to cut the umbilical cord
  
  

C-SECTION

If I have a c-section, I'd like:

• my partner present at all times during the operation
  
  
• music of my choice to be played during the procedure
  
  
• the screen lowered a bit so I can see my baby being delivered
  
  
• the baby to be given to my partner as soon as he's dried, if appropriate
  
  
• skin-to-skin contact in the operating room, if appropriate
  
  
• the chance to breastfeed by baby in the operating room, if appropriate
  
  
• to have my baby rejoin me  in the recovery room as soon as possible
  
  

CORD BLOOD BANKING

I'm planning to:

• donate cord blood to a public bank
  
  
• bank cord blood privately
  
  
• neither
  
  
• NAME OF BANK COMPANY BEING USED FOR THIS SERVICE_______________________________________
  
  

POSTPARTUM

After delivery, I'd like:

• all newborn procedures to take place in my presence, including first bath
  
  
• my partner to stay with the baby at all times if I can't be there
  
  
• to stay in a private room
  
  
• to have a cot provided for my partner
  
  

I'd like:

• 24-hour rooming-in with my baby
  
  
• my baby to room-in with me only when I'm awake
  
  
• my baby brought to me for feedings only
  
  
• to make my decision later depending on how I'm feeling
  
  

I have read and understand the hospital’s Golden Hour. I understand “skin to skin” and the importance of this time post birth. Please delay any procedures and weighing baby until the baby has had an attempt at initial breastfeeding.