Planning your beautiful birth requires thought, research and a willingness to change courses as needed. Building your birth blueprint should reflect your ideal birth and your understanding that sometimes, after a grand design is made adjustments and compromises may come up in order to preserve the safe structure and overall outcome of your birth. Please take time to design your beautiful birth and feel free to come back and make adjustments as needed. Our Family Please tell us all about your family. Birthing Parent Name* Email* Phone number* Home Address* Partner Name Phone number Family Members and Support People: Additional Phone/Emails Guess Date* Referred From: We Would Like You To Know: Setting Chosen for Birth* Birth Center Home Hospital Other Location Address Care Provider* CPM CNM Family Practitioner OB Perinatologist Name Next Leading Up To Labor Before Labor Preferences As long as the baby and I are healthy, I would like to go at least 10 to 14 days over my due date before inducing labor As long as baby and I are healthy I prefer to go into labor naturally with no restrictions on the length of my pregnancy If NST observation becomes necessary after my due date, I am willing to participate and support this I would like to discuss the option of induction before my due date I am planning a cesarean and would like to schedule the date I am planning a cesarean and would like to wait for early signs of labor to begin before setting a time Environment Environment Preferences When arriving at my birth location I wish for my support team to stay with me at all times I would like the option of staying at in the hospital regardless of my dilation If I am less than 4 cm dilated I would like the option of returning home I prefer No residents or students be present during my stay for my birth I Have tested positive for GBS and would like to discuss my options to avoid antibiotics with my provider Unless medically necessary I choose to not have a IV or Hep Lock upon arrival When in my space I would like Space Preferences Birthing bed Birthing ball Bean bag chair Birthing tub/pool/shower Birthing stool Squatting bar Dimmed lights For people entering the room to speak softly To wear hospital clothing To wear my own clothes during labor and delivery To wear headsets during my labor and delivery My birth photographed My birth filmed/videotaped Continuous fetal monitoring Intermittently monitored to allow for as much mobility as possible Vaginal Checks Vaginal Check Preferences Please obtain my permission before stripping my membranes during a vaginal exam I prefer to have no vaginal exams until I go into labor I prefer to have only one vaginal exam on or around my due date During a vaginal exam, I prefer at no time to have my membranes broken unless there is an emergency situation I prefer minimal internal vaginal exams or at my request only I would like no internal vaginal exams, within reason, during my labor until I have an urge to push Back Next Induction After 37 weeks I would like to try and bring labor on naturally before medical induction. I have researched information on Natural Start Preferences Breast stimulation Walking Herbs Enema Castor oil Chiropractic Acupuncture Sexual intercourse If my water breaks at home with no contractions I prefer to Ruptured Membranes Preferences Wait 6 hours before being induced Wait 12 hours before being induced Avoid induction and talk to my provider about alternative treatments such as antibiotics Medical Induction techniques I am comfortable with are Medical Inductions Preferences Stripping Membranes Prostaglandin gels (Cervidil) Misoprostol (cytotec) AROM Artificial rupture of membranes Pitocin Pain Relief Pain Relief Preferences Please only offer pain medications if I ask for them Please suggest pain management options for me if I appear too uncomfortable to handle the pain Please discuss pain management options for me as soon as possible After medical guidance for pain relief, I would appreciate some private time with my partner to discuss which pain management technique or medication I would like to use I want to be able to walk around and move as I wish while in labor I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor Please always keep my door closed while I am in labor For comfort during labor I have researched or taken classes on Comfort Preferences Breathing techniques Distraction techniques Hypnotherapy Acupressure Acupuncture Massage Doulas Color therapy Deep (or guided) relaxation Water/bath/shower Medical pain management I am comfortable with is Medical Pain Relief Preferences Narcotics Therapeutic rest Epidural Sedatives Tranquilizer Back Next During Labor In my second stage Second Stage Preferences I would like to move freely and utilise any positions that feel right throughout labor and delivery I would like to labor down until I feel the instinct to push I would like to have active coaching to tell me when to push Please encourage me to breath properly for slower crowning to avoid tears As long as baby and i are healthy, I prefer no time limits on pushing I would like warm compresses in between pushes Please no manual vaginal stretching If pushing for several hours, I am comfortable with interventions to ease delivery Please no episiotomy, I am comfortable with natural tears (unless there is a medical emergency) I would like local anesthetic for any repairs During vaginal birth my preferences are Vaginal Birth Preferences To view the birth using a mirror To touch my baby's head as it crowns To catch my baby and pull it onto my abdomen as it is born For my partner to catch my baby For the doctor to catch my baby For spiritual or religious reasons, I would like the room to be totally silent as the baby is born For our baby to hear our voices first To have the lights dimmed for delivery or, if it is daylight, to access only natural light As long as my baby is healthy, I would like my baby placed immediately skin-to-skin on my abdomen with a warm blanket over it During cesarean birth my preferences are Cesarean birth Preferences If a cesarean birth is not an emergency, please give my partner and me time alone to think about it before asking for our written consent My partner is to be present at all times during the cesarean birth I would like to discuss having my support persons attend the procedure with the anesthesia team I would like the baby to be shown to me immediately after it's born I would like to have contact with the baby as soon as it is possible in the delivery room I prefer to have a hand free to touch the baby We would like to photograph or film the birth of our baby in the operation room If possible, please discuss anesthesia options with me (including morphine options) Please respect my wishes to be quiet or only speak of the birth during the operation If my baby is healthy, I would like to hold my baby and nurse it immediately in recovery I would like to sign any waivers necessary to permit me to be with my baby in recovery If I am unable, I would like my partner to be the baby's constant source of attention until I am able to bond with baby Please pay special attention to our nursing needs in recovery. I may need some extra help nursing after the operation I would like to have my catheter and IV removed ASAP after my recovery period Please discuss with me what I can expect to feel immediately following the procedure Please discuss my post-operative pain medication options with me before or immediately after the procedure In my third stage Third Stage Preferences Please wait for the umbilical cord to stop pulsating before it is clamped Please allow my partner to cut the umbilical cord I would prefer for the placenta to be born spontaneously without the use of pitocin, and/or controlled traction on the umbilical cord I would like to have routine pitocin given to me after the placenta is born I would like to avoid routine pitocin after the placenta is born unless there are any signs of hemorrhaging I will be taking home my placenta and have arranged for this service before the birth Back Next After the baby is born Newborn Care Newborn Care Preferences I would like my partner to be present with the baby at all times, if medical attention is needed I would like to delay newborn procedures until we have had time to bond and breastfeed I would like all newborn routine procedures to be performed in my presence If possible please perform routine procedures without removing baby from skin to skin I would like all newborn routine procedures to be performed right away I would like to delay the administration of eye drops until after breastfeeding and bonding has occurred Please do not administer eye drops to my baby, I am willing to sign a formal waiver I would like my baby to receive a routine injection of vitamin K immediately after birth I would like to delay the administration of vitamin K until after breastfeeding and bonding, unless medically necessary I would like only the oral vitamin K to be given to my baby Please do not administer vitamin K to my baby, I am willing to sign a formal waiver I prefer any immunizations be postponed to a later time Immunize the baby according to normal procedures Please bathe my baby after we have had time to bond Please do not bathe my baby at all We would like to give our baby his/her first bath using our own non-toxic baby products Please do not circumcise my baby I would like my baby circumcised Please use a local anesthetic Please delay circumcision as long as possible Please do routine PKU Testing after 24 hours We decline routine PKU testing at the hospital and have made other arrangements for this procedure at a later date this week We would like to wait, and delay the PKU testing until we are ready to leave the hospital My baby is to be exclusively breastfed My baby is to be formula-fed exclusively I would like to combine breastfeeding and formula feeding I would like to see a lactation consultant as soon as possible for guidance Please do not use formula, pacifiers, artificial nipples, or sugar water without specific permissions Please place my baby on pulse oximetry after 24 hours of life to rule out any obvious heart conditions If baby needs NICU care I would like NICU Care Preferences For all care procedures to be explained to me To be transported with my baby if possible My partner to go with the baby To breastfeed or express my milk for my baby To have as much bodily contact with my baby as possible Back Next Notes Additional Information Back Submit Thank you! 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Planning your beautiful birth requires thought, research and a willingness to change courses as needed. Building your birth blueprint should reflect your ideal birth and your understanding that sometimes, after a grand design is made adjustments and compromises may come up in order to preserve the safe structure and overall outcome of your birth. Please take time to design your beautiful birth and feel free to come back and make adjustments as needed.
Please tell us all about your family.
Thank you!
We will help you with any question you may have with your options and have your blue print to you shortly.
