Birth Preferences Form

Please fill out this form carefully. Leave blank any technical terms or questions with which you are not familiar, or any questions you prefer not to answer, or to answer in person. The more information you can provide the better.

• Name *
  First Name Last Name

• General Birth Preferences

• What preferences for privacy do you have?
  Attendees limited to only those listed above My LMC can add additional medical staff as needed Others may be allowed in the room on a case by case basis Knock before entering sign placed on door I don't have any special preferences for privacy
  
• Is there anyone you do not want to attend your birth?
• Are medical students or trainee staff allowed to visit you during labour?
  Yes No
  
• What preferences for the birthing room do you have?
  Dimmed lights Curtain pulled/blinds drawn Music (let me know which songs you would like) Hypnotherapy audio (Hypnobabies is available for hire) Aromatherapy (let me know which scents you prefer)
  
• Do you have any other general preferences?

• Pain Relief Preferences

• What are your preferences for natural pain relief techniques?
  Birth pool Shower Hot application Cold application Massage Sacrum counter-pressure Acupressure Loving touch from a loved one TENS (Elle TENS is available for hire) Sterile water injections Hypnotherapy (Hypnobabies is available for hire) Meditation/visualisation/affirmations/focal points Changes in position Rhythmic movement Birth ball Birth stool
  
• What are your preferences for pharmaceutical pain relief?
  Entonox gas Pethidine Epidural Please don't offer me pain medication, I will request it if desired

• Intervention Preferences

• Which birth interventions do you want to completely avoid (unless an emergency necessitates it)?
  All of them Restriction of food/drink Restriction of movement IV/catheter Routine time limits Continuous monitoring Vaginal exams Manual dilation Membrane sweep Artificial rupture of membranes Induction Directed pushing Episiotomy Vacuum Forceps Induced placenta delivery Cord traction Immediate cord cutting
  
• What are your preferences regarding informed consent for birth interventions?
  I would like to be informed of the reasons, risks, and benefits of any intervention that needs to be performed before I consent I do not need to be informed before I consent
• Do you have any other preferences regarding interventions?

• 2nd & 3rd Stage Preferences

• What are your preferences for the 2nd and 3rd stage of labour?
  Quiet during contractions Remind me to slow down pushing when crowning to avoid tearing I would like a hand mirror to see baby emerge Delay cord clamping I would like to donate cord blood I would like to store cord blood I would like to keep the placenta to take home
  
• Who would you like to catch the baby?
• Who would you like to cut the baby's umbilical cord?
• Do you have any other preferences for the 2nd and 3rd stage of labour?

• Emergency Cesarean Preferences

• Who would you like to stay with you in the event of an emergency cesarean?
• Do you have preferences for mediation?
  Non-drowsy anti-nausea meds No sedatives No preferences
  
• Would you prefer a spinal or epidural anesthesia?
  Spinal Epidural Not sure
• Which is your dominant hand to keep free of equipment?
  Right Left
• Would you like to have the "gentle cesarean" method of delivery?
  Yes No I would like more information
• Would you like the surgery explained to you as it happens?
  Yes No Not sure
• Would you like the drape lowered at delivery to see the baby lifted out?
  Yes No Not sure
• Would you prefer sutures or staples?
  Sutures Staples Not sure
• Do you have any other preferences in the event of an emergency cesarean?

• Baby Care Preferences

• What are your preferences for cleaning your baby immediately after delivery?
  Wipe down baby but leave vernix Clean off everything
  
• What are your preferences for initial baby care?
  Perform all exams immediately after birth as per normal Delay non-essential exams for skin-to-skin (eg. weight and measurement; essential exams, such as APGAR, are performed immediately after birth) Perform exams on my chest where possible (exams are otherwise performed on an examination table) Skin-to-skin for at least 1 hour Rooming in - nursery not required
  
• Vitamin K injection?
  Yes No Not sure
• Antibiotic eye ointment?
  Yes No Not sure
• How do you plan on feeding your baby?
  Exclusive breastfeeding Exclusive donor milk Exclusive formula milk Both breast and formula milk
  
• If breastfeeding, would you like a visit from the breastfeeding consultant?
  Yes No Not sure
• Do you have any other preferences for baby care?
• Should be Empty: