What do you want for your birth?
Used with Permission by Author Jennifer Rosenberg
www.jenrose.com
Email Jennifer Rosenberg

Birth Preferences- (copy and paste the text to Notepad or Word to use this!)

Delete any statements that do not apply. Feel free to cut and paste to place *your* priorities on page one. Feel free to reword anything in here to suit *your* needs. This is a list of possible desires and alternatives only. Not every alternative is available in every area, nor will every birth plan be followed to the letter. This is designed to facilitate communication among birth team members, partner, mother, caregiver, doula, staff, etc. The ideal is to read the entire thing, then pick and choose the five or so issues that are most important to you.

People

My name is:

This is my (first, second, etc) baby. We do/do not know the sex of the baby and according to (ultrasound/amnio) the baby is a (boy/girl). The name/s we are considering are:____________ (or, We have not decided on a name yet.)

My birth support people include:

(partner)
(mother/mother in law)
(doula)
(sister/sister in law)
(friend)
(other)

If I have a cesarean section, I would like the following people in the room with me: (pick one or two of the above)

 Photography/Video

We will be recording the birth using a camera/videocamera, which will be the responsibility of (doula, partner, other support person).

I prefer that pictures/video be taken:

_ which are tasteful and not graphic

_ which show as much of the actual birth as possible

_ which show the baby as much as possible.

 I specifically want/do not want pictures of

_ Labor

_ Support people

_ Pushing

_ Crowning

_ Birth of the head

_ Birth of the body

_ Placenta

_ When we first hold the baby

_ Bath/footprinting

_ When the baby first latches on and nurses

_ "group pictures" of mom/baby/support people

_ The actual birth if there is a c-section.

 Pain management:

_ I would like medication as soon as possible. Please let me know when it is available.

_ Feel free to offer medication to me as an option when we discuss methods of coping with contractions.

_ I don't know if I'll want medication or not, so let me ask for it if I decide I want it. I want to try other ways of working with my labor before I decide to use medication.

_ I prefer to labor and birth naturally, without medication for pain if at all possible. I will discuss pain medication with my support team before making a decision if it becomes an issue.

_ Birthing my baby without drugs is extremely important to me. Please help me work with my labor and use other ways of coping with my contractions. Pain medication should only be used as a last resort.

 Type of medication preferred:

_Sterile water Papules (subcutaneous injections of sterile water)

_Gas and air (UK)

_Stadol (or other narcotic)

_Intrathecal

_Epidural

_Other______________________

 In general, when I use medication:

_I react quickly to a small dose

_I generally need a fairly large dose to get an effect

_It lasts longer than I expect

_It wears off more quickly than I expect

_It does exactly what I expect it to

 I have the following drug sensitivities:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 Fetal Monitoring:

_ I find the monitor reassuring. It is fine to use it throughout my labor.

_ I prefer to use the EFM intermittently unless there is a medical reason to use it continuously.

_ If I need to use a monitor continuously, I would prefer to have the telemetry unit so I can continue to change positions and walk around.

_ I find the belts to the monitor uncomfortable. If it is possible, I would prefer to be monitored by handheld Doppler intermittently or by having someone hold the EFM transducer by hand intermittently.

_ I am concerned about the use of ultrasound. Please use a fetoscope when monitoring my baby.

 Vaginal exams:

_ They don't bother me.

_ I find them uncomfortable.

_ Please do them as infrequently as possible.

_ Please do them when I ask to let me know how far I have come.

_ I am a survivor of sexual abuse or assault. Please do vaginal exams as little as possible, give me plenty of warning and ask my permission before touching me.

_ Please tell me all the information you get from an exam:

dilation, effacement, station, position of the cervix and rotation of the baby's head. This helps me and my support team know when there has been progress, even if it is not in dilation.

 Second stage:

_ I want as much guidance as I can get in pushing.

_ I want to see how I do. Give me suggestions or guidance if I don't seem to be getting the hang of it after a few contractions.

_ I prefer to use non-breathholding techniques and take my time. Please let me find my own way unless there is a pressing medical need to get the baby out more quickly.

_ I don't have any preference for positions in the second stage. Whatever the caregiver is comfortable with is fine with me.

_ I want to move around and see which positions are comfortable for pushing.

_ I would particularly like to try the following positions:

yes/no/maybe Squatting (with squat bar or support people: on bed)

yes/no/maybe Birth Chair

yes/no/maybe Side-lying

yes/no/maybe Semisitting (in bed, feet on footrests)

yes/no/maybe Hands-and-knees

yes/no/maybe Supported squat or "dangle"

yes/no/maybe Sitting on toilet (for pushing only)

 _I particularly want to avoid the following positions ________________ because _____________________ (Some examples might be: I particularly want to avoid the hands and knees position because I have had knee surgery. I particularly want to avoid a semisitting position because I've had a previous tailbone injury.

I want to avoid having my feet in the stirrups and pushing the baby out from a height, because I don't feel very secure with the idea of pushing from a height.)

 Birth

 Care of the perineum

_ Please cut an episiotomy only if it is necessary to get the baby out quickly.

_ I would prefer to tear rather than to have an episiotomy.

_ Please cut an episiotomy if it looks like I will tear.

_ Please use perineal support, hot compresses, and oil to help prevent a tear.

_ Please help me to birth in a perineum friendly position. I feel comfortable with:

_squatting

_hands and knees

_dangle

_side lying

_ I would prefer that you cut an episiotomy. (possibly because of prior perineal injury which will be repaired at that time.)

 Cord care

_ Please allow the cord to stop pulsing before clamping it if possible.

_ Please clamp the cord right away.

_ Please have (Dad, Mom, ___________) cut the cord.

_ Please do not clamp the cord before the placenta delivers.

_ Please clamp the baby's side only, and allow the mother's side to drain.

_ Please save the cord blood. We have made the following arrangements for donation/storage. ______________________

 Placenta

_ Please encourage Mom to stay upright (sitting up) until the placenta delivers

_ Please allow the placenta to deliver without traction if possible.

_ We would like to keep the placenta.

_ We would like to see the placenta.

_ We do not want to keep the placenta.

 Infant Feeding

Breastfeeding:

_We will be breastfeeding.

_Please do not offer bottles or artificial nipples of any kind. If supplementation is medically necessary we prefer to use

_Spoon

_Syringe

_Eyedropper

_Softcup feeder

_SNS system (or Lactaid)

_Fingerfeeding

to prevent nipple confusion.

 _Please do/do not offer my baby a pacifier.

If supplements are necessary, we prefer to use

_Pumped milk

_Formula

if possible.

Bottle feeding:

We will be bottle feeding.

 Rooming in:

_I prefer to room in with my baby.

_I want my baby with me at all times.

_If my baby must be separated from me for any reason, I would like ___________ (husband, friend, relative, etc.) to accompany the baby.

_I would like my baby with me during the day, and with the nurses at night.

_Please bring my baby to me whenever he/she cries, or whenever s/he needs feeding.

_I'm bottle feeding, and prefer that the nurses give the night feeding.

_____________ other

 Discharge:

_I have lots of support at home, and feel that I can rest more comfortably there. I plan on leaving as soon as possible after the baby's birth.

_I would like to leave as soon as I feel ready to go, and anticipate that that will be 12 hours or so after the birth.

_I feel I will probably get more rest in the hospital, and my insurance company provides for (24/48) hours of postpartum hospitalization. I prefer to stay as long as my insurance will allow.

_I will be paying for a stay longer than my insurance allows, and plan on staying in the hospital for (1 day, 2 days) extra.

Copyright 1996, Jennifer Rosenberg. Used with permission of the author