Hospital Birth Preferences Template

May 22

Examples of things you may want in your notes section:

Any triggers or personal history that you feel may affect your labor and birth experience.
Declining an IV port. You could use this if you’d like “I would like to labor without an IV port/saline lock. Please prepare intramuscular Pitocin in case I hemorrhage postpartum. If I do hemorrhage, I consent to an IV postpartum.”
Delivery of the placenta: standard practice is active management: administering Pitocin after the birth of the baby and traction (tugging) on the cord to speed up delivery. You can ask to attempt delivery without either one or both of these if you would like: “I do not want 3rd stage Pitocin unless I am showing signs of hemorrhage” and “I would like to attempt delivery of the placenta without traction on the umbilical cord.”
Induction preferences: e.g. I do not want cervidil, I would like Cervidil instead of misoprostal or cytotec, I do not a foley balloon, I would like to exhaust all other options before Pitocin, I would like to avoid AROM, I would like to AROM before trying Pitocin.
No perineal massage/pressure during pushing.
Uncoached or open glottis pushing.