Birth Preferences

My Name________________________

Due Date________________________

Caregiver's Name_______________________________

Caregiver's Number_____________________________

Hospital/Birth Center_____________________________

Telephone #____________________________________

Support Person__________________________________

Home Phone_______________Cell Phone_____________

Baby's Doctor____________________________________

Telephone #_____________________________________

Emergency Contact_______________________________

Telephone #_____________________________________

Relationship_____________________________________

My Labor and Delivery

These are my preferences. I understand that circumstances may arise that will require changes in the plan

Blood Type_______________________________________

Allergies_________________________________________

Current meds_____________________________________

any problems during this pregnancy___________________

I want my support person with me during labor Yes No

I have attended a childbirth class                     Yes No

If possible I would like to avoid

I.V.

Enema

Forceps

Episiotomy

Constant monitoring

During Labor I would prefer

To be in a Labor Room Birthing room

I would like to stay upright as long as possible Yes No

I would like to walk around                            Yes No

I would like to take a shower                         Yes No

My partner wishes to cut the cord                   Yes No

I want to breastfeed right after the birth         Yes No

I would like rooming in                                 Yes No

If the baby is a boy I want him circumcised    Yes No