Birth Preference Worksheet printable pdf download

Name:

Doctor or midwife:

Attendant(s):

Use this checklist to guide your discussion with your practitioner. Note your preferences and give copies

to your caregivers when you arrive at the hospital.

LABOR

I'd like to have my labor photographed or filmed.

I'd like to be offered an epidural or other pain medication as

soon as possible.

I'd like to move around freely during labor.

I'd like to be allowed to push when and how I feel I should.

I'd like intermittent or wireless fetal monitoring.

I'd like to be coached on when to push and for how long.

If I need an IV, I prefer a saline or heparin lock.

I'd like to choose the position I deliver in.

I'd prefer to let my water break naturally.

I'd like to view my baby's birth using a mirror.

I'd like to use labor props, such as:

I'd like to touch my baby's head as it crowns.

If I have a c-section, I'd like to have the drape lowered so I

can view the birth.

Please don't offer me any pain medication. I plan to use

natural pain relief techniques.

I'll decide whether to use pain medication as my labor progresses.

AFTER DELIVERY

If my baby has to be taken from me for medical treatment,

I'd like to hold my baby skin-to-skin immediately

I'd like my partner or attendant to go along.

after delivery.

I plan to exclusively breastfeed my baby while in the

I'd like my baby to be dried off before being brought

hospital or birth center.

to me.

I'd like to meet with a lactation consultant for breastfeeding

I'd like to delay clamping and cutting the umbilical cord.

guidance.

I'd like my partner or attendant to cut the umbilical cord.

I plan to feed my baby formula.

I plan to donate my baby's cord blood to a public bank.

I'd like to be consulted before my baby is offered a bottle

or a pacifier.

I plan to store my baby's cord blood in a private bank.

If my baby's a boy, I want him to be circumcised at the

I'm not banking my baby's cord blood.

hospital.

I'd like to delay newborn procedures such as bathing and

measuring for the first hour to give me a chance to feed

and bond with my baby.

I'd like all procedures done and all medications given to my

baby to be explained to me beforehand.

I'd like my baby evaluated and bathed in my presence.

Birth Preference Worksheet

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