birth preferences

Client's Name

Where are you planning to give birth?At homeBirth centerSomeone else’s homeAirBnB/Hotel

Street address of birthing location

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Anything your midwife needs to know about finding your house?

My Birth Team

Who do you envision being present at your birth?

The following people are NOT allowed to be present:

Are you planning on having a doula?yesnonot sure yet

Are you planning on having a photographer?yesnonot sure yet

Doula's name:

Photographer's name:

Childcare plans for older siblings if applicable:

Labor Preferences

Preferred birth room:

Do you want me to bring my birth pool?yesnoI have my own birth poolnot sure yet

I think I prefer:minimal conversation/noisean upbeat atmosphere and conversationnot sure yet

What kind of support feels best for you during labor?encouragement and verbal supportphysical touch like massage or counterpressurebeing left alone unless I ask (except to listen to the baby and monitor my vitals)I’m not sure yet

Pushing + Birth Preferences

Perineal support:I want perineal support from my midwife to help avoid tearing as baby crownsplease don’t touch unless it’s absolutely necessaryI’d like guidance in doing my own perineal supportnot sure yet

Someone else:

Other pushing preferencesI’d like to see the birth in a mirrorI want my midwife to count while I pushOther

Other pushing preferences:

Immediate Postpartum

My default is to put baby on your chest and preserve the golden hour as much as possible with minimal interruptions for taking vitals. I never cut and clamp the cord before it's done pulsing except in very rare emergencies.

Cord preferences:cut cord once it stops pulsingcut cord after placenta is deliveredcut cord at newborn exam (1 hour after birth)I’m planning a cord-burning ceremonyI’m planning a lotus birth

Who will cut the cord?myselfpartnermidwifeother

Person who will cut the cord:

I'd like to take an herb bath postpartumyesnonot sure yet

Any other preferences?

Newborn Decisions

I have discussed and know the risk and benefits of the following newborn informed choices and I’d prefer:

Vitamin K preferencesAdminister Vitamin K injectionAdminister Vitamin K drops orallyDo not administer Vitamin K

Erythromycin preferencesAdminister erythromycin eye prophylaxisDo not administer erythromycin eye prophylaxis

Do you plan to breastfeed?yesnonot sure yet

Would you like baby’s cord blood typed? (required for RH- clients)yes ($10)nonot sure yet

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