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
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