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Labor Preferences

Your labor, your choices, and your surroundings will all play a part in shaping this unforgettable experience. Make sure they resonate with your heart and soul.

My preferred method of delivery is:

Vaginal birth

C-section

If you’re planning a vaginal delivery, have you had either of the following?

A prior C-section

Surgery on your uterus

Neither

In the delivery room, I want:

Dim lighting

Birthing ball

Music that I will provide

Minimal sound

Blankets and/or photos from home

Aromatherapy scents that I will provide

One of my support people taking photos

Other

Other Delivery Room Preferences

I want the following people in the delivery room with me:

Note: Hospital policy may restrict the number of people who are allowed to visit you in your room at one time.

I want the following help for managing labor discomfort and pain management:

Natural techniques

Epidural

IV medications

Please do not offer me pain medicine; I will request it if needed

Both or Showers

Breathing techniques

Massage

Hypnobirthing techniques

Music

Other

Other Discomfort Management

When it comes time to push, I want:

To view the birth using a mirror

To touch my baby’s head as it crowns

The hospital staff to help me with pushing techniques

To be able to feel the urge before starting to push

Your Plan for the Unexpected

It may seem like the plan is set in stone, but sometimes things don’t go according to it. A little research and discussion with your doctor or midwife before birth day can help prepare you for anything that might come up!

I would prefer the following options to help prepare my cervix for labor, if necessary (also known as cervical ripening)

Dinoprostone cervical ripening vaginal insert, FDA-approved

Dinoprostone cervical ripening gel, FDA-approved

Pill (Cytotec®/misoprostol), not FDA-approved for cervical ripening

Balloon catheter, some are FDA-approved

Other

Other medical options

In the event an induction is necessary, I would prefer the following options to help with contractions:

Walking around

Nipple stimulation

My doctor or midwife will break my water

Other

Other contraction preferences

In case of interventions such as vacuum, forceps or episiotomy, what requests can I make?

If I need any of these procedures, please discuss with me beforehand

I would prefer not to have an episiotomy unless medically necessary

I would prefer not to have forceps used

I would prefer not to have a vacuum used

If I need a C-section and it’s not an emergency:

If possible, I’d like to have a moment alone or with my partner/family/other prior to the procedure

I’d like to have a support person present for the procedure

I’d like a sheer screen to watch, if possible

I’d like to have the procedure explained as it happens

I’d like to have music playing

If possible, I’d like to have immediate skin-to-skin contact with my baby

Other

Other c-section preferences

I want to hold my baby for the first time:

Immediately after delivery (skin-to-skin)

After my baby has been wiped clean

After my baby has been wiped clean and weighed

Other

Other holding baby for first time preferences

I want the following medications for my baby:

Hepatitis B vaccination

Other

Other medications for baby

Procedure for the umbilical cord and placenta:

My partner or support person will cut the cord

I prefer delayed clamping or cutting of the cord

I want to take my placenta home

I’ll stick with the hospital’s standard procedures for the cord and placenta

I want the following collected for banking:

Blood

Umbilical cord

Placenta

All of the above

I’d like it sent to:

I want to feed my baby with:

Breast milk

Formula

Both

I prefer my baby not to receive bottles at this time

My baby may receive a bottle of breast milk if needed

If breastfeeding, I want to start:

As soon as possible after delivery

When I feel comfortable

I would like to see a lactation consultant in the hospital, if possible

If my baby is a boy:

I want him circumcised before leaving the hospital

I do not want him circumcised before leaving the hospital

This information is meant to be shared only with your doctor or midwife and the hospital admission staff. Be sure to complete all fields or check each box that applies to you:

I have completed the following:

Hospital admission forms, if applicable

Insurance forms

Cord blood/placenta banking materials and instructions

Other

Other Checklist Items

Please note that I:

Have group B strep

Am Rh-incompatible with my baby

Am positive for herpes

Have gestational diabetes

Take the following prescription medications:

Have the following medication allergies:

Other

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Labor Preferences

I want the following people in the delivery room with me:

Your Plan for the Unexpected

I do not want him circumcised before leaving the hospital

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