My Labour, Birth and Postpartum Preferences: Getting to know me and my family
This form gives you a chance to describe your preferences, values and concerns for your labour, birth and postpartum experience to the people who will be caring for you during your hospital stay. It may also remind you of your own wishes for your childbirth experience.
Your choices and preferences are important. However, being flexible and open to changes is also important since no one knows how your labour will progress. Unplanned events may change the care you need. Language like, “If possible…,” “unless medically necessary…,” “I prefer…,” tells the staff that you know that a change in plans is sometimes needed.
Include the options you prefer if the “unexpected” should occur. This helps you remain actively involved in your care.
Complete a draft copy of this form and talk about it with your doctor or midwife, then make up a final copy.
Take one or two extra copies with you to the hospital to share with those caring for you.
Begin to gather information early in your pregnancy that will help you make choices and decisions.
Talk to your doctor, midwife, doula and nurses about the issues and feel free to ask questions.
Go to aimsireland.ie to learn about your choices and options during pregnancy, labour and birth.
Register early for antenatal classes.
Read the information from the hospital you are attending and look at http://www.bump2babe.ie – a consumer guide to maternity services in Ireland.
Go to www.aimsireland.com for more information on Irish maternity services.
My Name: ___________________________
Booking Reference Number: ______________________________
I attended prenatal classes: Yes No
I am in a research study/studies Yes No
Study name(s): ________________________________________
Please contact: ________________________________________
What you need to know about me and my family: Begin with your names and a brief introduction about yourselves. Describe general health, any problems during pregnancy, any special needs or cultural preferences.
My support person or persons for labour and birth will be:___________________________________________________________________
My translator’s Name and Phone details: _____________________________________________________________________
Ways to work with the pain of labour
There are many things you can do to help relax and move your labour forward. Check off the ones that you would like to try throughout your labour. Please put a tick mark beside what you would like to have happen:
I prefer to labour and birth without medication
I want to have the least amount of pain possible
I need more information before I can decide what I prefer. I need to know:
I understand my options. I want to make my decision(s) during labour.
I hope to use the following during labour:
drink fluids eat snacks breathing
relaxation massage rest
encouragement walking imagery
position change making noise hula (movement of hips)
lunging squatting rocking
shower birth ball bath/birth pool (if available)
music (bring your own) focal point ice pack
TENS (bring your own) hot water bottle sterile water injection
listen to my hypnobirthing tracks through earphones slow dancing
Drug methods of pain relief
Our thoughts about special procedures during labour: Think about your feelings and thoughts about procedures such as:
Our concerns or fears about labour/birth:
What is important about the birth for us:
Think about special things you would like to happen for your birth.
What is important to us if unexpected events occur:
If I need a Caesarean birth, I would like to talk about all parts of it such as:
Ways that will help make our baby’s first hours and early days special and memorable:
Our concerns or questions about the care of our baby:
If our baby is sick and needs special care we would like:
Our plans for support after we go home:
Other wishes and ideas:
What my doctor or midwife wants my other caregivers to know:
Developed by 42 Weeks/AIMS Ireland (Sept 2013). Adapted from: “Pregnancy, Childbirth and the Newborn: The Complete Guide”, by Penny Simkin, Janet Whalley and Ann Keppler (3rd Edition), 1991. Deephaven, MN: Meadowbrook Press and Building Better Care Committee BC Women’s (July 1999). Revised January 2007 Special Contribution: Diane Donaldson, Childbirth Education, Vancouver B.C. and Salvation Army Grace Hospital, Scarborough, Ontario
Download and print a copy of this template in pdf format here: birth-preferences-template