Section 1: General Birth Info 1. What is your planned birth location? (Required) Hospital Birth Center Home Birth 2. If applicable, what is the name of the Hospital or Birth Center? 3. What is the name of your medical provider? (Required) 4. Who will be present at your birth? (e.g. husband, doula, photographer, family, etc) + Add another person 5. Are you okay with student nurses or doctors being present? Yes No 6. Which of the following do you plan to have? (Required) Vaginal birth Planned induction Planned Cesarean Section 2: Labor Preferences Which types of pain management medication do you plan to use? Epidural IV pain medication Nitrous oxide None/unmedicated For each of the following, please indicate how willing you are to accept each intervention. Intervention Yes Possibly Not unless medically necessary pitocin induction pitocin augmentation foley catheter induction membrane sweep AROM What labor tools do you plan to use? Rebozo Shower Labor tub Birth ball / peanut ball Heat/cold therapy Counterpressure Other: Which of these would you like to be a part of your birth experience? Free movement Natural lighting only Dark, dim lights Candle/twinkle lights Music playing Monitor noise off Eat/drink freely Verbal encouragement Labor at my own pace (no outside direction) Other: Please indicate if you have a preference on the following. If no preference, leave blank. Saline lock / heparin lock only Intermittent monitoring only Wireless monitor (for use in water) No intrauterine monitor No fetal scalp electrode Minimal vaginal exams No vaginal exams Other: Section 3: Delivery Please indicate your willingness to accept these interventions. Intervention Yes Possibly Not unless medically necessary Forceps Vacuum Episiotomy Which of these would you like available to you during delivery? Deliver in a position of my choosing Use squat bar Use birth stool Water birth Warm compress on perineum Coached pushing Push only when I feel the urge Be offered a mirror Other: Section 4: Postpartum For baby (leave blank if no preference): Option Yes No Immediate skin-to-skin for 1 hour Wait to clamp cord until white / not pulsing Baby wiped/towelled off Immediate breastfeeding Bath for baby Utilize formula if needed Utilize donor breastmilk if needed Utilize pacifier Utilize nursery Baby stays with mother at all times Hep B vaccine Vitamin K injection Eye ointment Other: For mom: Allow placenta to deliver without assistance No visitors Keep placenta Visitors allowed: Other: Section 5: In case of C-Section Support person: Please select any of the following options you prefer: Gentle C-section Clear or dropped drape Immediate skin-to-skin Vaginal seeding
