Birth Preferences Template

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:                              ___________________________

Doctor/Midwife:                      ______________________________

Booking Reference Number: ______________________________

I attended prenatal classes:        Yes            No

Where: _______________________________________________

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

• nitrous oxide (also called Entonox)
• narcotics             Pethadine
• epidural

Our thoughts about special procedures during labour: Think about your feelings and thoughts about procedures such as:

• Monitoring your baby’s heart
• Breaking your waters (rupturing your membranes)
• Assisted birth with vacuum or forceps
• Getting fluids in a small tube in your arm (IV fluids)
• Starting labour by medications or helping a slow labour by getting medications

___________________________________________________________________

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.

• A variety of pushing positions: gravity-positive positions – squatting, supported squatting, kneeling, side-lying, on all fours, semi-sitting, sitting on the toilet or birth-stool.
• Allow time needed for pushing in second-stage if mother and baby are doing well.
• Self-directed pushing unless direction is needed.
• Warm compresses to vaginal area for relaxation and comfort.
• Dimmed lights and quiet surroundings.
• Caring for my baby skin-to-skin to help my baby recover from birth and stay warm.
• Cutting the cord.
• Use of cameras, video recorders (some restrictions may apply).
• Other: (ie. delayed cord clamping; physiological delivery of placenta)   _________________________________________________________________

What is important to us if unexpected events occur:

• All procedures are described and the issues explained.
• My support person is included in all decisions.
• The need for transfer of mother or baby to special care areas discussed.
• Other:  ________________________________________________________________

If I need a Caesarean birth, I would like to talk about all parts of it such as:

• Consent for procedure signature/signing.
• Types of medication.
• Types of anesthesia (epidural, spinal, general).
• Types of preparation – IV, catheter, shave.
• Wearing of glasses and/or contacts, removal of jewelry.
• Having my support person with me.
• Contact with baby.
• Music (bring in own battery operated personal stereo/MP3 player)
• Me or my partner to hold our baby skin-to-skin in the theatre.
• Other: ________________________________________________________________

Ways that will help make our baby’s first hours and early days special and memorable:

• Partner or Labour Support Person is given the chance to cut cord.
• Skin-to-skin care.
• Photographs or videotaping done (some restrictions may apply).
• Cultural or religious customs respected. (Please describe specific wishes) ________________________________________________________________
• Other: ________________________________________________________________

Our concerns or questions about the care of our baby:

_____________________________________________________________________

If our baby is sick and needs special care we would like:

• Skin-to-skin care of baby as soon as possible
• Help to start expressing/pumping milk within 6 hours of the birth of our baby
• For us to be able to stay overnight in the “Parent’s Sleep Room” if possible
• Other: _________________________________________

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