Full Name *

First Name

Last Name

Partner's Name

If applicable

First Name

Last Name

Today's Date *

MM

DD

YYYY

Due Date / Induction Date *

MM

DD

YYYY

Please note that I:

Have Group B Strep

Am Rh incompatible with baby

Have gestational diabetes

My delivery is planned as:

Vaginal

C-Section

Waterbirth

VBAC

I'd like the people I specify below present:

Before labour

During labour

During labour, I'd like:

Music played (I will provide)

The lights dimmed

The room as quiet as possible

As few interruptions as possible

As few vaginal exams as possible

Hospital staff limited to my own doctor and nurses (no students, residents, or interns present)

To wear my own clothes

To wear my contact lens the entire time

My partner to film AND/OR take pictures

My partner to be present the entire time

To stay hydrated with clear liquids and ice chips

To eat and drink as approved by my doctor

I'd like to spend the first stage of labur:

Standing up

Lying down

Walking around

In the shower

In the bathtub

I'm not interested in:

An enema

Shaving of my pubic area

A urinary catheter

An IV, unless I'm dehydrated

A heparin or saline lock

Is okay

Is not okay

I'd like fetal monitoring to be:

Continuous

Intermittent

Internal

External

Performed only by Doppler

Performed only if the baby is in distress

I'd like labour augmentation:

Performed only if the baby is in distress

First attempted by natural methods such as nipple stimulation

Performed by membrane stripping

Performed with prostaglandin gel

Performed with Pitocin

Performed by rupture of the membrane

Performed by stripping of the membrane

Never to include an artificial rupture of the membrane

For pain relief, I'd like to use:

Acupressure

Acupuncture

Breathing techniques

Cold therapy

Distraction

Drugs (epidural, painkillers, nitrous oxide)

Hot therapy

Hypnosis

Massage

Meditation

Reflexology

Standard epidural

TENS

Walking epidural

Nothing

Only what I request at the time

Whatever is suggested at the time

During delivery, I would like to:

Squat

Semi-recline

Lie on my side

Be on my hands and knees

Stand

Lean on my partner

Use people for leg support

Use foot pedals for support

Use a birth bar for support

Use a birthing stool

Be in a birthing tub

Be in the shower

As the baby is delivered, I would like to:

Push spontaneously

Push as directed

Push without time limits, as long as the baby and I are not at risk

Use a mirror to see the baby crown

Touch the head as it crowns

Let the epidural wear off while pushing

Have a full dose of epidural

Avoid forceps usage

Avoid vacuum extraction

Use whatever methods my doctor deems necessary

Help catch the baby

Let my partner catch the baby

Let my partner suction the baby

I would like an episiotomy:

Used only after perineal massage, warm compresses and positioning

Rather than risk a tear

Not performed, even if it means risking a tear

Performed only as a last resort

Performed as my doctor deems necessary

Performed with local anesthesia

Performed by pressure, without local anesthesia

Followed by local anesthesia for the repair

Immediately after delivery, I would like:

My partner to cut the umbilical cord

The umbilical cord to be cut only after it stops pulsating

To bank the cord blood

To donate the cord blood

To deliver the placenta spontaneously and without assistance

To see the placenta before it is discarded

Not to be given Pitocin/oxytocin

If a C-section is necessary, I would like:

A second opinion

To make sure all other options have been exhausted

To stay conscious

My partner to remain with me the entire time

The screen lowered so I can watch the baby come out

My hands left free so I can touch the baby

The surgery explained as it happens

An epidural for anesthesia

My partner to hold the baby as soon as possible

To breastfeed in the recovery room

I would like to hold the baby:

Immediately after delivery

After suctioning

After weighing

After being wiped clean and swaddled

Before eye drops/ointment are given

I would like to breastfeed:

As soon as possible after delivery

Before eye drops/ointment are given

Later

Never

I would like the members of my family who I specify below:

To join me and the baby immediately after delivery

To join me and the baby in the room later

To only see the baby in the nursery

To have unlimited visiting after birth

I'd like the baby's medical exam and procedures:

Given in my presence

Given only after we've bonded

Given in my partner's presence

To include a heel stick for screening tests

To include a hearing screening test

To include a hepatitis B vaccine

Please don't give the baby:

Antibiotic eye treatment

Sugar water

Formula

A pacifier

I'd like the baby's first bath given:

In my presence

In my partner's presence

By me

By my partner

I'd like to feed the baby:

Only with breastmilk

Only with formula

On demand

On schedule

With the help of a lactation specialist

I'd like the baby to stay in my room:

All the time

During the day

Only when I'm awake

Only for feeding

I'd like my partner:

To have unlimited visiting

To sleep in my room

If we have a boy, circumcision should:

Be performed

Not be performed

Be performed later

Be performed with anesthesia

Be performed in the presence of me AND/OR my partner

As needed post-delivery, please give me:

Extra-strength acetaminophen

Other drugs if necessary (including opiates)

Stool softener

Laxative

If the baby is not well, I'd like:

My partner and I to accompany it to the NICU or another facility

To breastfeed or provide pumped breastmilk

To hold him or her whenever possible

After birth, I'd like to stay in the hospital:

As long as possible

As briefly as possible

Jewish Options

Rituals such as Shabbat candle lighting if applicable

Prayer/Blessings: Humanistic

Prayer/Blessings: Theistic

Jewish music including kol ha'olam kulo

Mikveh ceremony before

Mikveh ceremony during

Mikveh ceremony after

Misheberach during labour for others: Humanistic

Misheberach during labour for others: Theistic

Jewish birth art as focal point

Jewish meditations/affirmations

Jewish education/theory about birth during prenatal visit #2