Birth Preferences
We are looking forward to working with you and your family to provide you with a
memorable birthing experience. Please read our guide to birthing at Stamford Hospital
before completing this worksheet. This is meant to be a checklist of options to consider.
You may opt to complete the entire worksheet or just the parts that are most important to
you. You may also choose not to use the worksheet at all. If you choose to complete this
form, it will not take the place of talking to your physician about your questions and
concerns.
After the worksheet is completed please review with your physician at your prenatal visit.
Keep a copy and place it in the bag packed for the day you give birth.
Name_______________________________________________
Physician____________________________________________
Due Date____________________
My delivery is planned as a: Vaginal_____ Cesarean _____ VBAC______
Childbirth preparation:
Hospital childbirth classes____
ASPO/Lamaze _____
Hypnobirthing _____
Bradley _____ Other_____________________________________________________
My primary support person for delivery is ____________________________________
First Stage of Labor
Environment:
Check as many as you would prefer.
I prefer dim lights and a quiet atmosphere
I would like to listen to music brought from home
I would like to wear my own clothes
Do you have any special requests for your labor environment?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Visitors
I would like to share this experience with my family and friends
I would prefer one support person
I have a doula as well as a personal support person
I would like the nurse to check with me before letting any visitors in my room
I would like to wait to decide about visitors
Who would you like to be present during your labor?
__________________________________________________________________
__________________________________________________________________
Who would you prefer not be present at your labor?
__________________________________________________________________
__________________________________________________________________
Comfort Measures:
Breathing techniques
Maintain mobility (walking, rocking, up to bathroom, etc.)
Massage or other integrative medicine services
Shower
Other
__________________________________________________________
Hydration:
You may choose a selection of these
Clear Fluids (Water, clear juice etc.)
Ice Chips
Saline Lock
IV
I prefer to leave this decision up to my physician
Blood Products
I do not plan to consent for blood products. I will discuss with my physician
I need more information about blood products. I will discuss with my
physician
I am willing to accept blood products if they are medically necessary.
Pain Relief Offers
Check only one.
Only if I ask
Offer if I seem uncomfortable
Offer as soon as possible
Pain Relief Options :
Check as many as you would prefer.
Non-Pharmaceutical
Relaxation
Positioning
Water (Shower)
Heat or Cold Therapy
Massage
Medication
Narcotics
No narcotics
Whatever my doctor recommends
Epidural
Epidural
Do you have any special requests or concerns related to your comfort in labor?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Induction/Augmentation:
Induction
I prefer not to be induced unless medically necessary
Augmentation
I prefer not to have my labor augmented unless medically necessary
Second Stage (Vaginal Delivery)
Pushing/Bearing Down:
Some of these options will depend on if you are medicated, how your labor is
going, and the health of your baby. You will be encouraged to change positions
frequently.
Spontaneous Bearing Down
Directed Pushing
Squatting/Birth Bar
Mirror
Birthing ball (you will need to provide your own)
Please complete if you would like to tell us more about your preferences:
How would you describe your ideal birth?___________________________________
What is your greatest fear about the birthing process?_________________________
Other preferences for Labor and Birth______________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Cesarean Birth:
Complete this portion if you are scheduled to have a cesarean birth.
Before
I would like my family/friends to accompany in my labor room as I am
prepared for my cesarean section
I would prefer just one support person with me as I am prepared for my
cesarean section
During
I would like _____________________________to accompany me in the
operating room (OR)
I would like to listen to music brought from home
I would like my arms to remain free from restrictive straps
I would like to avoid any sedatives to be given while in the OR
I would like sedation after the baby is born
I would like my physician to announce the sex of the baby
I would like myself or my family/friend to able to discover the sex of the
baby once brought to our side
In the event that my baby needs to be transferred to the nursery I would like
my support person to accompany him or her
In the event that my baby needs to be transferred to the nursery I would like
my support person to stay with me
I would like to initiate skin-to-skin/breastfeeding as soon as possible
I would like to have blood collected from my baby’s cord to be stored
Recovery
Upon returning from the operating room I would prefer visitors to wait in the
waiting room so my partner, baby and I have some time to bond
Upon returning from the operating room I would prefer visitors to be waiting
in my recovery room
I would like to initiate skin-to-skin contact and/or breastfeeding immediately
once I am in recovery
Cesarean or Vaginal Delivery
Placenta
I would like to take my placenta home with me
Please dispose of my placenta
Cord Cutting: (This is only an option for vaginal deliveries)
Choose one
Partner to cut cord
Partner prefers not to cut cord
Partner not sure about cutting cord
Antibiotic Eye Ointment
None. Requires mother to have a cervical culture done at the time of delivery.
Discuss with your Obstetrician.
Delayed for one hour
Immediate
Mother Baby Unit
Feeding Baby :
Choose one feeding method
Breast feeding only
Bottle feeding only
Combination (not recommended in the early newborn period)
No pacifiers unless used for circumcision pain management
I will bring my own pacifier
Circumcision :
Please choose only one category or leave blank if your baby is a girl.
None (Check here if you do not intend to have the baby circumcised, or if
you do not intend to have him circumcised at the birth place.)
Yes, in the Hospital
Do you have any special cultural or religious needs?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Is there anything else you would like us to know about your or your family?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________