EMPOWERED BIRTH
begins here.
Birth Preferences
Full name: Due Date:
Please call me:
Support person's name:
Support person (2) name:
Doula (if applicable):
Birthing Location:
Provider's Name:
I am comfortable with students: yes no
Health information (you):
my group b strep test was: positive negative unknown
my blood is Rh negative: yes no
I have gestational diabetes: yes no
I am allergic to:
please note:
Disabilities or injuries: yes no
please note:
pregnancy complications: yes no
please note:
other important health/pregnancy/illness information:
Health information (baby):
please note any pertinent health information for baby
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IN LABOR
I am planning for a:
vaginal birth VBAC
cesarean birth water birth
my goals for my experience are:
support people I would like in my space:
partner support person parents
doula other children my siblings
other:
in labor I would like to:
have my support person continually available
stay hydrated without an IV
have an unconnected saline-locked IV
be free to eat and drink
listen to my own music
utilize aromatherapy
have control over lighting
wear my own clothing
have privacy + minimal staff in room
avoid cervical exams when possible
avoid augmentation medications and methods
avoid medical pain management
have freedom of movement
have access to labor support tools
fetal monitoring preferences:
continuous external monitoring
intermittent external monitoring
intermittent doppler monitoring
avoid internal monitoring
monitoring only used for distress
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IN LABOR
(if needed) induction/augmentation preferences
rank in order of preference
______ nipple stimulation
______ assisted rupture of membranes
______ prostaglandins
______ pitocin
______ stripping membranes
______ balloon catheter
positions + tools I would like to try include:
a birthing ball the toilet
the floor the bed
hands and knees side-lying
squatting a birth stool
walking rebozo
a peanut ball sitting
to manage pain + discomfort I would like:
counter pressure acupressure
massage TENS unit
relaxation tools water therapy
reflexology (comb) nitrous oxide
sterile water injections IV pain medications
pudendal block hip squeezes
walking epidural standard epidural
other:
additional labor preferences:
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DURING DELIVERY
when pushing + delivering I would like to:
direct my own pushing efforts
choose my own pushing positions
freedom to push out of the bed
freedom to be in the water
try a birthing stool
try squatting
try hands and knees
try side lying
have guided/coached pushing help
during the delivery I would like:
a mirror episiotomy only if necessary/with consent
perineal massage warm perineal compresses
spontaneous pushing guided pushing
to touch the baby's head to help deliver my baby
my support person to deliver to avoid instrumental delivery
if instrumental delivery is needed, I'd prefer:
vacuum assist forceps assist provider preference
if cesarean delivery is needed, I would like:
a second opinion
to have exhausted all options
to be conscious
support person with me the whole time
extra support person in OR
skin-to-skin in OR
delayed cord clamping
my arms free
a clear drape
other:
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AFTER DELIVERY
immediately after birth, I would like:
baby skin-to-skin with me
support to tell me sex of baby
baby cleaned and swaddled
baby skin-to-skin with support if I'm unable
delayed cord clamping for _______ minutes
cord blood banking
to avoid pitocin
placenta to deliver on its own
to see my placenta
to keep my placenta
I plan to feed my baby: I would like lactation assistance:
at the breast yes
at the bottle no
breastmilk only
formula only
human donor milk if needed
formula + breastmilk
FOR BABY
requests for baby include:
no eye ointment
no vitamin K
no hepatitis B vaccine
no pacifier
1+ hour uninterrupted skin to skin
delayed bath for ________ hours
no bath
circumcision
no circumcision
parent/provider present/participating for all baby's needs/procedures
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Birth Priorities
Assuming all have the same shared desire of “healthy mom, healthy baby,”
this is the prioritization of other hopes + desires I have for my birth.
1 = Highest priority
12 = Lowest priority
_______ Unmedicated birth
_______ Access to epidural/medical pain management tools
_______ Avoidance of internal monitoring
_______ Control over environment (lights, music, candles, guests)
_______ Avoidance of cervical exams
_______ Intermittent/telemetry monitoring
_______ Privacy (control over number of staff in/out)
_______ Access to tub/shower
_______ Freedom of movement
_______ Vaginal birth
_______ Freedom to eat
_______ Time for “normal” labor to progress
*please do this activity with any birth support person!
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