Birth Wishes Form During labor would you like To bring music? To dim the lights? To wear your own clothing? To take pictures and film the birth? What else would help you feel comfortable in your labor room?How would you like labor to begin? Would you like labor to start naturally, even if you go “post dates”?Are you comfortable with the idea of induction, how do you feel about: Stripping Membranes? Prostaglandin Gels? Pitocin?Once you are in labor would you like: To labor at home as long as possible? The option to return home if you are not in Active labor when arriving at the hospital?Once you are admitted to the Hospital (if choosing a hospital birth): How would you feel about an IV or a Saline Lock? Have you ever had an IV before? Do you feel like you will be able to stay hydrated and nourished by eating and drinking?Who do you want with you in your labor room?NameRelationship Are you comfortable with having medical staff and residents in attendance? Do you wish to have freedom to move and walk as you choose?As long as you and the baby are doing fine, would you like: To monitor the baby’s HR intermittently rather than using a Continuous Electronic Fetal Monitor? To refuse the use of Internal Heart Rate Monitors unless medically necessary? To allow labor to move at it’s own pace, free of stringent time limits?For any discomfort during the first stage of labor (dilation) would you like to try: Changing Positions? Equipment? Non-medical Comfort Techniques? How would you like to try changing positions? Walking Standing Hands & Knees Sitting Squatting What type of equipment would you like to try? Birthing Ball (exercise ball) Birthing Bar Birthing Tub What type of comfort techniques would you like to try? Acupressure Bath/Shower Breathing techniques/Distraction Self Hypnosis Massage Hot/Cold Therapy (Ice, Hot Packs) TENS machine What are some other coping techniques you may have used in your life that you can bring into your birth? What do you do when you’re feeling sick, have a cold, or are under stress?How do you feel about the use of Pain Relief Medication during your birth? Do you want to have a natural birth? Would you like your caregivers to let you know when a good time to use medication would be? or would you prefer to ask for it, only when/if you feel like you need it? Do you have a goal of 4cm dilation or more before the use of Pain Relief Medication?If you are comfortable with the use of medication would you prefer? Regional Analgesia (an epidural and/or spinal block) Systemic Medication (nitrous oxide and/or Demerol) What if labor slows or stalls? Would you like to try natural means to speed it up, such as walking, eating, changing positions? How do you feel about breaking waters as a means to speed labor up? What about medication such as Pitocin? How do you think you would feel if labor began to slow down? How long or short would you like your labor to be?During The Second Stage of Labor (“pushing”) would you like to try different positions, such as: Semi Reclining? Side Lying? Squatting? Hands and knees? Whatever feels right at the time? When it is time to push would you like: To do so instinctively, bearing down when your body gives you the “urge to push”? To be coached on when to push and for how long? During the birth, would you like: To view the birth with a mirror? To touch your baby’s head as it crowns? For the room to be as quiet as possible? To risk a tear or birth over an intact perineum rather than an episiotomy? Your Partner to help catch the baby? If you have a Cesarean Birth would you like: Your partner with you at all times, even during administration of the spinal block? Your Doula to remain with you during the birth for support and information? To have the screen lowered a bit so you can see the birth of your baby? Your partner to hold the baby skin to skin after the birth? To breastfeed your baby in the recovery room? If a Cesarean Birth became necessary, how would you feel? What could you do to ensure that this birth is still a positive experience?After the birth, would you like: To wait for the umbilical cord to stop pulsating before it is cut and/or collect blood for cord blood bank? To deliver placenta naturally or choose active management of 3rd stage (Pitocin to help the uterus contract and deliver the placenta)? To hold your baby right away, skin to skin, putting off any procedures that are not urgent, such as: erythromycin for the baby’s eyes, routine vitamin k, swaddling, diapering, washing off vernix? Your partner to cut the umbilical cord? How do you feel about the use of routine oxytocin after you deliver your baby? Do you Plan to: Breastfeed exclusively? If you baby is a boy would you like him to be circumcised? Stay in the hospital overnight? Will your partner be staying; will they need a cot? Would you like to have a private room? SharePinTweetShare0 Shares