General Information

Your name (required)

Partner's name

Due Date

Allergies

Health Care Provider Name

Hospital/Birthing Center where you plan to deliver

Labor induction/augmentation
If I go past my due date and there are no health risks for me or my baby, I would prefer
not to be inducedto be induced

Notes

I would prefer trying the following methods to induce labor. Choose any of the following.
Stripping or breaking membranesProstaglandin gelCastor oilHerbsWalkingSexual intercoursePitocin

Notes

Environment

I would like the following to be present during labor:

I would like the following to be present during actual birth:

Notes

Please select from the following
I would like to bring music.I would prefer dim lighting.I would like to wear my own clothes.I would prefer to stay in one room during labor, birth, and post-delivery if available.I would like to be able to film baby's birth.I would prefer no students to be present.I would like to be able to walk around; mobility is important to me.I would prefer a warm bath over walking. Please let me try that if I do not feel up to walking.

Notes

Equipment
I would like the following equipment available to me. If unavailable, I would like to bring them with me, if possible.
Birthing bedBirthing ballBirthing stoolBirthing pool or tubShower

Notes

Preparation
I would prefer to be able to eat and drink during labor.I would prefer no IV unless absolutely necessary.If I need an IV, I would like to use a heparin or saline lock.

Monitoring
I would prefer no monitoring to be done if there are no signs of distress.I would prefer external monitoring if monitoring is necessary.I am comfortable using an internal monitor.

Anesthesia - Pain medication
I would prefer to try laboring without pain medication. I will ask if I would like something for pain. Please do not ask me.I would like to try nitrous oxide before being offered an epidural.I would like to try fentanyl before an epidural.I would like an epidural.

Notes

First Stage of Labor
I would like the option of returning home if labor is not progressing.I would like no time limits on laboring and prefer labor not to be augmented unless medically necessary.I would prefer my water not be broken during labor.I would prefer vaginal exams kept to a minimum.I would like encouragement throughout labor.

Notes

Second Stage of Labor
I'd like a mirror present to view birth.I'd like to be able to touch baby's head when it crowns.I'd like coach and/or nurse to support my legs when I push.I'd like to be able to try any position comfortable during pushing.I would like to wait to push until I feel the need even if I am fully dilated.I would like no time limits on pushing.I would like counting to help me push.

Notes

After Birth
I'd like my partner to catch the baby.I'd like to have baby placed on my chest immediately after birth.I'd like to cut the cord myself.I'd like to have my partner cut the cord.I'd like to wait on cutting the umbilical cord until it stops pulsating.My partner does not wish to cut the cord. Please do not ask.I would like to see my placenta after birth.I do not wish to see my placenta after birth. Please do not show it to me.I would like to bank baby's umbilical cord blood.I would like to donate my baby's umbilical cord blood.I'd like to be discharged as soon as possible.

Notes

Caesarean Section
I would like to avoid a c-section if possible.If c-section is necessary, I would like my partner present.I would like to touch the baby after birth.I would like my partner to hold the baby after birth.I would like the screen lowered so I can view the birth.I would like to breastfeed my baby as soon as possible.

Notes

Breastfeeding
Please choose one of the following:
BottlefeedBreastfeedBreastfeed and bottlefeed
I would like to see a lactation consultant.

Notes

After Birth Baby Medications
I wish my baby to have the Hepatitis-B vaccine.I do not wish my baby to have the Hepatitis-B vaccine.
I wish my baby to have erythromycin eye ointment.I do not wish my baby to have erythromycin eye ointment.
I wish my baby to have the vitamin K shot.I prefer my baby to have oral vitamin K if available.I refuse vitamin K.

Notes

Additional Comments

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