Birth Interventions
& Options
Please check the options you feel are most appropriate for you given where and with whom you have chosen to birth. It is ideal if you find out your options in advance of filling out this form. Ex: if you tell us that you want to use a labor pool for pain management and a birthing stool during pushing, yet you do not have access to either where you are birthing, then it does not help us support your desires or help you in preparing for your birth. If you have questions, we will discuss them at our prenatal consultation so that we are all very clear about your desires.
BEFORE LABOR BEGINS:
I expect, and trust, that my practitioner will seek my opinion, and that of my partner, on all issues that may affect my birth experience or that deviate from these preferences.
If the baby and I are fine, and if I go past my estimated due date, I would like to wait until I go into labor naturally. I have or will discuss this with my Provider.
If my water breaks at the onset of labor and there are no signs of infection, I would like to wait at least 24 hours before an induction. I have or will discuss this with my Provider.
If my baby is overdue, prior to induction, I would like to try the following techniques first (with the knowledge and support of my doctor or midwife):
FIRST STAGE OF CHILDBIRTH: LABOR
First Stage, Phase I - Latent Labor
General Background:
Upon entering my hospital or birth center, it is crucial for me that I will not be separated from my partner(s) at any point during labor or birth including triage.
Environment:
While I understand and can appreciate the need for training and teaching, I don't think I will want residents or students walking in and out during my labor and delivery. Please respect my wishes on this issue during labor/delivery and keep my room private.
Ideally, I would like my environment to:
Personal Style:
I would like to wear my own clothing since it is more comfortable than a gown.
I would like to wear my contact lenses unless removal becomes medically necessary.
I would like my partner to photograph labor. Photos/video of the birth itself is not allowed in the hospital. (Specify: rated G (could be shown to almost anyone/no private parts exposed) – rated X (would be for private viewing ONLY/not censored at all)
I would like the hospital or birthing staff to know that I may have my own way of laboring -- walking, swaying, moaning, grunting, cursing, laughing, etc. I would be grateful for the personal space to do this comfortably without feeling hushed, rushed and/or judged.
Triage:
In triage, I would like to stay out of the bed since I will need to manage contractions.
In triage, I would like to start preparation for medication: get hep lock/IV, put on gown, consult for anesthesiology asap. In anticipation of this, I will not have eated for several hours.
*Discussion Point: Internal Exams*
First Stage, Phase II - Active Labor - Getting to 10 cm
Exams:
Eating / Drinking:
I understand that I will be working hard. Therefore:
I would like no restrictions on food or drink.
If hospital rules do not allow food, I want access to clear fluids, like water, warm broth, Gatorade®, hot tea, laboraid, popsicles, etc. I will bring my own supplies.
Preparation:
Instead of an IV drip being started immediately, I would like no heparin lock and to drink normally or have a hep lock to be considered instead of an automatic IV.
Vital Signs:
Since mobility is important to me, I have discussed with my OB/Midwife that I would like Intermittent Monitoring (ACOG Standards), using:
*Discussion Point: Fetal Monitoring*
I feel comfortable with continuous fetal monitoring, even though my ability to move around will be limited, using:
Pain Relief:
My birth partner and I would like to take a few moments to privately discuss my pain-relief options before a decision is made.
I would like the opportunity to try non-medical, non-invasive pain-relief methods. Some therapies I feel would be useful for me include:
Pharmacological pain reduction is important to me. I would like access to:
Ideally, I would like to have freedom to stand, walk, rock, use my physioball, the bathroom, shower and move as my body dictates. I have discussed these desires with my OB/Midwife.
I am interested in having access to certain birthing equipment. It is highly suggested that you first check the availability of each at your place of birth. If available, I would like to use:
First Stage, Phase III - Transition
I understand that transition is unpredictable. I may throw-up, my water may break if has not already, and/or I may expel other bodily fluids. I am appreciative of help that reduces my anxieties and my sense of vulnerability.
At this point, my body may be most sensitive. If I am feeling that my husband, support person or staff member's voice and/or touch feels too much, I will indicate so.
SECOND STAGE OF CHILDBIRTH: PUSHING AND DELIVERY
Pushing
Coaching Preferences (that I have discussed or will discuss with my OB/Midwife):
I trust my body's instincts to push my baby out naturally.
Time Limits:
As long as it is clear that my baby's heartbeat is good and strong and that she/he is receiving sufficient oxygen, I would like to be free of time limits on pushing. It is important to me to allow my body to operate in its natural rhythm and time-table.
Positions:
If my doctor or midwife feels that pushing may not be progressing efficiently, I would like to be reminded that sometimes changing positions helps. Because I may be very internally-focused, I would like to be encouraged to alter to one or more of the following delivery positions. Women most commonly need to change positions ta least every 30 minutes:
Vaginal Delivery:
Ideally, I would like to avoid an episiotomy. To that end, I would like my practitioner to support me with:
with the flow and force of my uterus.
If my OB/Midwife thinks I need an episiotomy, I am okay with their decision.
I would like to be given the option to view my baby's entry into the world by using a mirror.
on my abdomen, covered by blankets.
If Complications Lead to a Cesarean Delivery:
Please keep communication open. If, at all possible, please wait for my express consent, or that of my partner, before initiating any procedure.
It is important to me that my partner(s) be present with me at all times during the birth.
Ideally, I would like to remain awake and aware, avoiding general anesthesia if possible.
Please discuss anesthesia options with me.
Please use a low-transverse incision on my uterus and abdomen.
Since I have had a cesarean, please use the same incision, if possible.
I would like the screen to be lowered, or be able to use a mirror, so I can witness my baby's entrance into the world.
Please leave at least one of my hands free so I may touch my baby when he or she is born.
Ideally, I would like the opportunity to videotape and/or photograph my baby's birth.
Assuming the baby is well, I would like to hold my baby on my chest and/or nurse my baby as soon as possible.
I would like the opportunity to see and/or photograph my placenta.
Please remove my IV and catheter as soon as possible following my baby's birth.
I would like to take my placenta home with me.
Please discuss options for postpartum medication, if needed, with me.
Please provide me with nutritious food and drink as soon as possible.
THIRD STAGE OF CHILDBIRTH: DELIVERY OF PLACENTA OR AFTERBIRTH
Ideally, I would like to deliver the placenta unassisted -- without Pitocin, uterine massage or cord traction. If a procedure is necessary, please explain it to me.
Assuming both baby and I are well after the delivery, I would like the opportunity to see the placenta. I understand that the placenta has been my baby's life support system, providing him or her with daily nutrients, warmth and eliminating his or her wastes. If possible, I would like my doctor or midwife to show me the maternal and fetal sides.
I would like my partner to have an opportunity to take a picture of the placenta.
I have heard that some families choose to take home the placenta and bury it beneath a new tree or in their garden. This provides rich nutrients to the soil, as well as a remembrance of the baby's birth. I would like this opportunity and I will sign the form required to do so.
IMMEDIATE NEWBORN CARE
Suction:
I would like my baby not to be suctioned unless medically necessary.
I would like my baby to be suctioned as soon as possible
In my ideal world, my healthy baby will be immediately placed on my chest. If this is the case, s/he will be above the placenta and I would therefore like to wait to clamp the umbilical cord. Please select only one of the following:
I would like the opportunity to cut, or have my partner cut, our baby's umbilical cord.
I would like to store my baby's umbilical cord blood. I have made arrangements with the hospital regarding this storage. Early cord clamping is not necessary to do this.
Administration of Eye Ointment:
*Discussion Point: About Eye Ointment*
I understand that it is routine to administer a thick antibiotic ointment, such as erythromycin, to newborn baby's eyes to protect against gonorrhea and chlamydia, as well as other bacterial infections, within the first hour of life.
Administration of Vitamin K:
*Discussion Point: Vitamin K*
I understand that in NY State, it is mandated by law that all newborns receive an injection of vitamin K. The new law, passed in 2014, is that it is given within the first 6 hours of life.
Other Newborn Procedures:
Ideally, with either a vaginal or cesarean birth, I would like to postpone "routine" newborn procedures until the 1 hour mark so that I have had a chance to bond with my baby.
I would like to have any additional newborn procedures thoroughly explained to us.
I would like for my birth partner(s) or me to be present during all newborn procedures.
I would like to postpone the Hep B immunization until a later time with our pediatrician.
*Discussion Point: Heparin/Saline lock*
*Discussion Point: Immunizations at Birth*
I prefer that the baby be gently wiped down
to remove fluids, and wrapped in a receiving
blanket instead of being bathed
It is important to us to have my baby washed
and bathed as soon as the hospital or birthing
center staff deems appropriate.
Circumcision:
*Discussion Point: Circumcision*
If the baby is a boy:
Rooming In - Separation Issues:
and in the nursery at others.
Visitations:
If my baby is not well:
if transported to another facility.
My postpartum care:
Additional Comments:
Click here to send this form
I have rested.
in the nursery.
Name of Hospital, BC or Home Birth:
OB/Midwife
Estimated Due Date:
Name:
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Please do not bathe, to allow my baby's vernix to continue to protect my baby's skin. Studies show the first bath would ideally be delayed at least 24-48 hours, reducing risk of infection, stabilizing the baby's blood sugar, improving temperature control, breastfeeding, maternal-infant bonding, etc.
(aka Provider, Caregiver, etc.)
get medication as soon as the hospital will give it to me.
