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Name: ___________________
My coach will be: ___________________ (husband)
Other support person(s): ______________ (doula)

I do not want:
· any induction or augmentation of labor that is not medically required
· medical students, nursing students, interns, or non-essential medical personnel observing during my labor or during the birth

Comfort measures during labor

I would like to have the following:
· Use of clear fluids (broth, juice), jello, ice, lollipops, hard candy.
· Use of my own pillows.
· Use of my own top or gown for labor and delivery.
· Walking around, as tolerated and if safe for baby and me.
· While in bed, freedom to move and reposition for comfort and well-being.

I will bring a CD player and use music or other recordings for relaxation.

The most helpful things I do when I am uncomfortable are: take warm baths/showers; receive massage, rock hips.

To relax, I listen to soothing music; rock in rocking chair; take warm showers/baths; use massage and/or aromatherapy.

Pain control for childbirth

I have taken a Childbirth Education Course in preparation for my first child's birth. It used a combination of methods. For this birth, I have prepared by taking a refresher course with a local childbirth educator, and by reading several books, including A Good Birth, A Safe Birth.. I have practiced breathing exercises and relaxation/stress reduction techniques.

I prefer no elective medication; please do not suggest it to me during labor. If I do request pain relief, I would prefer to have a fifteen-minute waiting period before the medication is provided, during which I try alternative methods of relief such as changing positions, a warm shower, or massage.

If needed, I would prefer epidural anesthesia. I understand that continuous fetal monitoring is required for epidural anesthesia.

I would like to avoid other forms IV or IM anesthesia or sedation, and in particular any medications that are likely to affect the baby's level of alertness immediately after birth.

PROCEDURES PRIOR TO OR DURING EARLY LABOR

Enema:
I do not want a fleets or a cleansing enema, at home or at the hospital.
Shave:
I do not want to be shaved.
Induction/Augmentation of Labor:
I would like for my labor to proceed at its own natural pace, and would therefore like to avoid measures such as amniotomy, stripping of membranes, and/or pitocin unless a specific medical need arises.
Fetal Monitoring:
I understand that intermittent fetal monitoring for assessment of fetal well-being is recommended by the American College of Obstetricians and Gynecologists, and that this usually consists of a 20-30 minute strip upon admission and re-evaluation at intervals depending on labor progress and fetal response. I would prefer that this monitoring be kept to an absolute minimum.
I would prefer that the intermittent monitoring of the baby be done by my midwife using a fetoscope rather than by electronic monitor, if at all possible.
I do not want internal fetal monitoring done without a strong medical justification given, and express permission from me or my husband.
Intravenous Access:
I understand that upon admission blood will be drawn for routine lab work, and that at that time tubing will remain in place and a heparin lock created.
If for any reason an IV must be connected, I do not want any medications administered through the IV without express permission from me or my husband.

PROCEDURES FOR DELIVERY

Vaginal Delivery

Leg Support:
Support of legs by my husband, stepdaughter, and/or nurses, if necessary.
Positioning:
I would prefer to deliver in a hands-and-knees position if possible. My second choice is squatting, using my husband and/or the squatting bar for support.
If the above positions are not possible (due to epidural or other interventions), I would prefer a left lateral position, particularly if the baby is in a posterior position.
Environment:
Elimination of excessive bright light and excessive noise at birth.
Episiotomy:
Episiotomy only if indicated, if I tear.
Perineal Massage:
I have done perineal massage at home to promote stretching of perineum.
I would like perineal massage done during the birthing process.
Anesthesia:
I would like local anesthesia for repair of lacerations or episiotomy.
Expulsion of Placenta:
I would like to deliver the placenta spontaneously, encouraged by breast stimulation from the baby suckling.

Cesarean Delivery
No one plans to deliver by c/s, but if that becomes an issue, I would like to have epidural or spinal anesthesia.
My husband and I desire to be together during a cesarean delivery. I am aware that my husband is there to support me, and that if general anesthesia is used, that support will not be needed. However, even if general anesthesia is used, I would like my husband to be present during the delivery so that he may bond immediately with the baby while I am still under anesthesia.
If the baby must be taken to the nursery, I would like my husband to accompany him/her. If I am alert, and the baby is stable, I wish to hold the baby before it goes to the nursery.

POSTPARTUM
Skin to skin contact on my abdomen as soon as feasible after birth.
Apgar evaluation to be done while baby is on my abdomen.
My husband does not wish to catch the baby or cut the cord.
Prefer that I hold the baby rather than have it placed under the heat lamps.
Postpone eye medication until after initial bonding is established, +/- two hours after birth.
Breastfeed as soon as baby and I are ready.
Allow parental/newborn bonding for as long as mother and baby are stable.
I would like rooming in 24 hours a day.
We would like to have our 2-year-old son visit baby and me during my hospital stay.

NEWBORN CARE
Pediatric Care and Patient Discharge Preferences
I would like early discharge (24-48 hours) after normal vaginal delivery. Our pediatrician (family practitioner) has agreed to this.
Our pediatrician (family practitioner) is:
Dr. _______________________________
I will have a pediatrician examine the baby while in the hospital.

In Case of Medical Problems With Baby
If baby must be taken from room, I would like myself and/or my husband to accompany the baby at all times.
If medical procedures must be performed on the baby, I would like for myself and/or my husband to be present at all times.
I plan to exclusively breastfeed our baby, and therefore request that s/he not be given artificial nipples of any kind, including bottles (formula or water) or pacifiers.

Circumcision
We have read the information about circumcision. We do not want our newborn son to be circumcised.