Name *

First Name

Last Name

During Labour I would like?

Select all, some, or none

To bring music

To dim lights

To wear your own clothing

To take pictures

To film birth

How would you like labour to begin?

Select some

Would you like labour to start naturally, even if you go “post dates”?

Stripping Membranes?

Prostaglandin Gels?

Pitocin?

Lets see how it goes... I'm open

As long as you and the baby are doing fine, would you like:

To monitor the baby’s HR intermittently rather than using a Continuous Electronic Fetal Monitor?

To refuse the use of Internal Heart Rate Monitors unless medically necessary?

To allow labour to move at it’s own pace, free of stringent time limits?

For any discomfort during the first stage of labour (dilation) would you like to try:

Walking

Standing

Hands & Knees

Sitting

Squatting

Birthing Ball (exercise ball)

Birthing Bar

Birthing Tub (not available in hospitals)

Robozo

Bath/Shower

Breathing techniques/Distraction

Massage

Hot/Cold Therapy (Ice, Hot Packs)

Do you have a goal of "xx"centemeter dilation or more before the use of Pain Relief Medication?

How dilated would you like to be IF you were to receive pain management?

4cm or less

5cm

6cm or more

If you are comfortable with the use of medication would you prefer?

Regional Analgesia (an epidural and/or spinal block)

Systemic Medication (nitrous oxide and/or Demerol)

What if labour slows or stalls?

Labour ebbs and flows, not all labour progress at the same rate, steadily, for the same amount of time. Your journey is on your own time.

Would you like to try natural means to speed it up, such as walking, eating, changing positions?

How do you feel about breaking waters as a means to speed labour up?

What about medication such as Pitocin?

During The Second Stage of Labour (“pushing”) would you like to try different positions, such as:

Semi Reclining?

Side Lying?

Squatting?

Hands and knees?

What ever feels right at the time?

When it is time to push would you like:

To do so instinctively, bearing down when your body gives you the “urge to push”?

To be coached on when to push and for how long?

During the birth would you like:

To view the birth with a mirror?

To touch your baby’s head as it crowns?

For the room to be as quiet as possible?

To risk a tear or birth over an intact perineum rather then an episiotomy?

Your Partner to help catch the baby?

If you have a Cesarean Birth would you like:

Your partner with you at all times, even during administration of the spinal block?

Your Doula to remain with you during the birth for support and information?

To have the screen lowered a bit so you can see the birth of your baby?

Your partner to hold the baby skin to skin after the birth?

To breastfeed your baby in the recovery room?

After the birth would you like:

To wait for the umbilical cord to stop pulsating before it is cut and/or collect blood for cord blood bank?

To deliver placenta naturally or choose active management of 3rd stage (pitocin to help the uterus contract and deliver the placenta)?

Your partner to cut the umbilical cord?

After birth, I would also like to hold off non-urgent procedures:

Some of these procedures are hospital protocol, or personal preference, not necessarily evidence based.

erythromycin for the baby’s eyes?

routine vitamin k?

swaddling?

diapering?

washing off vernix?

Do you Plan to:

We all have ideas of how we will parent, this doesn't necessarily mean you're going to do all, some, or none of what you planned. What you vision is still very much important to the tone of how you want to care for your babe.

Breastfeed exclusively?

If you baby is a boy would you like him to be circumcised?

Stay in the hospital overnight?

Will your partner be staying, will they need a cot?

Would you like to have a private room?