Whom will you invite to attend/witness the birth?
What are your environmental preferences (lighting, noise level, music, etc.)?
What are your film/video preferences (check one)?
- Yes, I want to record the event with video
- No just cameras
- No recording devices of any kind
- A hospital gown
- My own clothing
- Internal fetal monitor
- External fetal monitor
What other labor preferences do you have (check all that apply)?
- I prefer to keep my contact lenses in unless I undergo anesthesia.
- Please keep pelvic exams to a minimum.
- I want to be able to walk around and change positions as desired.
- I want to be able to drink when I'm thirsty.
- I plan to use breathing, hypnosis, massage, or other pain management techniques.
- I want a room with a tub.
- I want an enema upon being admitted.
- I want to use a birthing ball.
- I'm planning an epidural, sedatives, tranquilizers, or narcotics.
- I want to be offered pain medications if I am obviously uncomfortable.
- I prefer to ask for them.
- I prefer that Pitocin be used if necessary.
- I want to use natural methods, like nipple stimulation, exercise, sexual intercourse, or herbs. (Consult your physician before using any method to augment labor.)
- I want my membranes to rupture naturally.
- I would like them ruptured artificially to speed up labor.
Which birthing position do you plan to use?
Which birthing accessories do you plan to use for comfort (check all that apply)?
- Squat bar
- Birthing stool
- Birthing chair
- Beanbag chair
- To let things be
- Some sort of augmentation
- To tear naturally
- To have an episiotomy
What other delivery preferences do you have (check all that apply)?
- Forceps and/or vacuum extraction should only be used if absolutely necessary
- I want to view the birth with a mirror
- I prefer to exclude medical residents or students from the birth
- I want assistance delivering the placenta
- I want to be told when and for how long to push
- I want to push when my body tells me to
- I want my partner present
- I want to be conscious
- I want video and/or pictures taken
- I want the screen lowered (or a mirror) so I can view the birth
- I want someone to explain the surgery as it's happening
- I want one hand free to touch the baby
- I want my partner (or a specific person) to cut the cord
- I want to begin breastfeeding immediately
- Other (list)
Please check all that apply.
- My partner wants to catch the baby
- My partner wants to cut the cord
- Delay cord cutting until pulsation stops
- I want my baby to be placed on my stomach immediately for ____ minutes of uninterrupted contact
- I want to postpone newborn procedures until we've had a chance to bond
- I want either myself or my partner to be with the baby at all times
- I want to delay eye mediation, Vitamin K injection, or vaccines for a certain length of time
- Pacifiers, bottles, or sugar water may be offered to my baby
- I want to begin breastfeeding within the first hour
- If my baby is a boy, I want him circumcised
- If my baby is a boy, I do NOT want him circumcised
- I want to begin breastfeeding as soon as possible
- I want unlimited visitation for parents
- I want to be moved with the baby, if necessary, to another hospital
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