Name *

First Name

Last Name

EDD: *

MM

DD

YYYY

Expected Delivery Location *

Please list the name and exact street address. For home birth enter "home" followed by the name of your transfer hospital of choice.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Lighting

Lighting can affect the progress of your labor because of the way it changes how your body process melatonin.

I would like to keep the lights dimmed.

I would like to provide, or allow my doula to provide, ambient lighting.

No preference.

I would like more information.

Sound & Smell

Please select all that apply.

I would like to bring my own music from home.

I would like to use essential oils/ aromatherapy .

I would like to be spoken to quietly, between contractions whenever possible.

No preference.

I would like more information.

Clothing & Mobility

Please check all that apply.

I would like to wear my own clothes during labor and birth.

I would like freedom of movement during labor (walking, standing, sitting, kneeling, using the birth ball, etc).

I prefer to move around or change positions in order to allow my labor to progress before trying medication.

No preference.

Nourishment & IV Fluids

One of the risks to IV fluids is the potential for them to cause edema (swelling) that can affect the initiation of breastfeeding and milk production. The ACOG recommendations for eating in labor were recently changed to support eating lightly during labor to avoid maternal exhaustion. Please check with your provider about policies for food and hydration. Please check all that apply.

I would like to eat lightly during labor.

I would like to drink clear liquids during labor.

I would like to avoid IV fluids by having a HEP-LOCK placed (IV catheter flushed with saline and capped for later use).

I prefer no IV fluids, and no HEP-LOCK (*Please discuss with me if this is your preference, as most hospitals require at least HEP-LOCK placement.)

I don't mind receiving intravenous hydration during labor.

No preference.

I would like more information.

Augmentation and Interventions

Please let me know if you need more information about the potential risks/benefits to induction, augmentation and intervention.

I would like to avoid induction, intervention and augmentation as much as possible. I would prefer to use movement and patience to progress labor.

I would prefer to wait for the amniotic membrane (bag of waters) to rupture spontaneously. If the need to have my water broken arises, please discuss this with me before breaking my water.

No preference.

I would like more information.

Sensation Management & Coping

By now, we will have discussed the risk/benefits to medical sensation management (epidural, nitrous oxide, etc) during a prenatal appointment, as well as the Fear-Tension-Pain cycle and how language affects the hormones your body produces during labor, some of which affect the way intensity of sensation is experienced. *If you're interested in hydrotherapy for sensation management, ensure that your provider supports it. Please select all that apply.

I would like to use hydrotherapy (shower or bath/birth tub) for comfort during labor.

I plan to hypnobirth.

I prefer to labor and deliver with no medical sensation management.

Please do not offer me any sensation management, if I decide to use medication or an epidural, I will ask for them.

I would like my birth support team to avoid using the word "pain" to describe labor, but instead "sensation" or "intensity."

I plan to use an epidural, and will use my safe word to ask for it.

I am considering using medical pain relief, but will decide when I am actually in labor.

Monitoring *

The type of monitoring your caregiver and delivery location provides can have a huge impact on mobility as well as comfort/coping during labor. It is important to find out what type of monitoring your provider supports.

I prefer to have my baby monitored intermittently (not continuous monitoring) as long as it is medically appropriate to do so.

If my baby needs to be continuously monitored, I prefer a portable monitor (if available, and if I am mobile).

No preference.

I would like more information.

Exams

I prefer to have as few cervical exams as possible. I understand that periodic cervical checks may be necessary.

No preference.

I would like more information.

Positions

Delivering prone (on one's back) decreases the pelvic floor outlet by 22% and brings an increased risk of tearing, as well as damage to the pelvic floor and perineum. Check with your provider about what positions they are comfortable with you pushing/laboring down and delivering in, as these standards of care vary from practice to practice.

I would like to push in a position of my choosing (squatting, kneeling, side lying, etc)

I would like to follow my body's urge to push, unless doing so is medically indicated.

I would like to hypnobirth, and prefer to labor my baby down using breath instead of forced pushing.

No preference.

I would like more information.

Episiotomy

There is evidence to suggest that tearing heals better and more easily than an episiotomy. Please check all that apply.

I would like to give informed, expressed consent before receiving an episiotomy.

I would prefer to tear than receive an episiotomy.

I would not like to know if I am going to be given an episiotomy.

I would like warm compresses and perineal pressure to avoid tearing.

Cord Clamping *

Some new studies have found that DCC can have a positive effect on both preterm and full-term babies. These benefits include an increase in placental transfusion, a 60% increase of RBCs and a 30% increase in neonatal blood volume. Another advantage of DCC is the decreased risk of iron deficiency anemia. By performing DCC, an additional 40 to 50 mg/kg of iron transfers to the newborn, which reduces the risk of the baby suffering from the severe side effects associated with iron deficiency. Common side effects of iron deficiency at birth include cognitive impairment and central nervous system problems. Check with your provider to ensure that they are able and willing to accommodate your preferences. Please note that DCC (delayed cord clamping) will only be done if it is deemed medically safe for the birthing person and infant to do so. Check all that apply.

I would like to delay cord clamping until the cord is white.

I would like to delay cord clamping until the cord stops pulsating.

I would like to delay cord clamping for 1 minute or more.

Other (please follow up to specify in the notes section below).

I would like my partner to cut the umbilical cord.

I am planning to use umbilical cord blood banking.

No preference.

I would like more information.

Infant Procedures *

During the first hour of life an infant is in a quiet alert state that they do not experience again until they are around one month old. This timeframe is ideal for bonding and, if planning to nurse, initiating breast crawl and first latch.

I would like immediate skin to skin.

I would like to delay infant procedures for one hour (Vitamin K shot, Erythromycin eye ointment, weighing and measuring).

I would like to be present for my baby's first bath.

I would like to delay my baby's first bath.

If my baby needs to leave my side for any reason I would like my partner to accompany them as much as possible

No preference.

I would like more information.

Feeding Baby

Please check all that apply.

I plan to exclusively breast/chestfeed my baby.

I do not plan to breast/chestfeed my baby.

I may have questions about breastfeeding or need help getting off to a good start.

I would like to give my baby time to attach and initiate feeding on their own (breast crawl).

If my baby needs to be fed anything other than my breastmilk for a medical reason, I would like to be informed first.

If necessary for my baby, I would like help learning how to hand express or pump my own milk.

I will be nursing on demand and whenever baby is fussy to help stimulate my milk to come in, and to soothe baby.

Placenta *

Some birth locations hold the placenta and do not release until after the safe window for encapsulation. If you plan to consume or encapsulate your placenta, ask your delivery location about their policies. Please check all that apply.

I would like to take my placenta home with me.

I would like more information on placenta encapsulation.

I would like a recommendation for a placenta encapsulator.

I do not have plans for my placenta, other than to thank it for its hard work as a one-time-organ.

Intersex *

About 1 in 1500 people are born intersex. If your child is born intersex, you can request to delay any procedures regarding their assigned sex. Please check all that apply.

If my child is born intersex I would like to delay immediate surgeries to change their anatomy (surgically assigned sex) until I can research the risks/benefits.

I would consent to surgically assigned sex before leaving the hospital.

I would like more information.

Circumcision *

If a boy, I would like my baby circumcised in the hospital.

If a boy, I would like my baby circumcised outside the hospital.

Not Applicable.

I would like more information on risks/benefits.

Operating Room *

Please check all that apply. Thinking about these possibilities may bring up a lot of mixed emotions. If you need to process anything on this list, or need more information I am here for you. As with all procedures, your provider will only accommodate within the realm of what is safest for yourself and your baby, so some preferences may not be accommodated for an emergency cesarean birth.

I would like my partner to stay with me at all times, including the OR for the birth, if possible.

I would like my doula present in the operating room, if possible

I would like to have music of my choice playing during the birth (if not an emergency cesarean).

I request. that talk among my providers focus primarily on the birth, as I will carry memories of this experience for many years.

I do not want my arms strapped down during the operation.

I would like to bring in essential oils/aromatherapy.

I do not want to have a surgical drape form a 'tent' over my head, which could make me feel trapped or isolated from the other people at the birth.

I would like a clear screen to see my baby being born.

Please lower the screen just before delivery so I may see the birth of our baby.

Please explain the surgery to me as it happens.

Medications & Procedures

I would like to have a slow delivery, with intent of stimulating the "vaginal squeeze".

If possible, and the cord is long enough, I would like my partner to cut the umbilical cord while my baby is in my arms.

I request cord clamping/cutting delayed until it stops pulsing. If possible, I would like the cord to continue pulsing after the birth so that my baby may start breathing on his/her own while still attached to the placenta.

I would like a non-drowsy anti-nausea medication, if possible and if necessary.

Please ensure all medications are suitable for breast/chestfeeding.

I would like a vaginal swab to give my baby the best microbiome possible. Please swab on baby, in their mouth and on my nipples for breastfeeding.

Please reinforce my uterus and use dissolvable stitches (double suture on my uterus and suture on the outside instead of staples, and please be sure that how I am sutured goes into my medical record for future medical staff to see when evaluating my candidacy for a VBAC).

I would like the IV catheter and oximeter to be placed on my (non-dominant) arm to give me a completely free arm to touch my baby.

I would like ECG leads to be placed on my back, to make my chest free for skin-to-skin contact.

I would like more information.

Recovery & Feeding baby

Please check all that apply.

I would like baby to go directly to my chest as quickly as possible, skin to skin. (If that is not possible then my partner or doula will do skin to skin).

Please don't swaddle baby or put a hat on them while they are skin-to-skin. I would like them to be able to move and I'd like to see them unobscured. To keep us warm, once baby is on my chest you can cover us with a warm blanket.

I would like the opportunity to breastfeed in the Recovery Room. I may need help to do this.

If I am physically unable to hold my baby with support, I would like my partner/support person to hold baby.

Please do not give me sedatives after the birth. I want to remember my baby's first day of life.

Once in the postpartum room and settled I would like to be alone with baby to nurse.

I would like my catheter out as soon as possible.

I am willing to be up and walking as soon as possible.

I would like to eat and have the IV removed as soon as possible after the surgery.

Visitors

If someone arrives to visit, please check with myself or my partner as to whether we are ready for company before allowing them in the room.

Please limit interruptions by grouping care provider visits as much as possible.

Separation & Baby Nursery

I would like to have minimal separation from my baby. If baby and I need to be separated for medical reasons, I would like my partner (or doula) to accompany baby to the nursery. I understand we cannot go into the nursery with baby but can watch through the window.

I would like the baby to go to the nursery at night. I understand this may affect the breastfeeding relationship and/or delay milk production.

I would like to decide this later.

I would like more information.

Room Accommodations

Hospital accommodations for the family in early postpartum vary widely. Find out if your hospital offers private or shared rooming, and if you will need to pay for a private room. Additionally, some shared rooms do not allow partners to stay overnight and adhere to hospital visiting hours.

I plan to request a private room once the baby is born.

I plan to stay in a shared room.

I would like to decide after the birth.

No preference.

I would like more information.