Microsoft word - birth options list.doc

General Information about your Birth

Birth facility:
 Hospital
 Alternative Birthing Center
 Home
I am choosing to have a
 Natural Birth
 Medically-Assisted Birth
 Planned Cesarean Birth (Gentle Cesarean page 7)
Names of those attending your labor and birth:
 Partner
 Doula
 Child
 Other support
I have prepared for my birth by taking/learning
 Childbirth education class
 Other class (education workshop, meditation, yoga, etc)
 Tools (breathing, visualization)
General Options
 As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy.  I would like to labor at home as long as possible, returning home if less than 5 cm dilated.  I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth  I understand that my baby’s size is subjective and should not be a reason for cesarean section.  I understand that amniotic fluid levels are subjective – I would want to try natural ways to balance the levels  I understand that amniotic fluid levels are subjective and should not be a consideration for a cesarean section.  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.  I would like to have no restrictions on food or fluids during my labor.  Unless absolutely necessary, I would like to avoid a cesarean.  If my baby is breech, I would like to attempt natural measures to turn baby before scheduling a cesarean.  If my baby is OP (Occiput Posterior which means baby is facing forward or “sunny side up”) I would like to attempt natural measures to turn baby before scheduling a cesarean.  If my baby is transverse (side-lying in uterus) I would like to attempt natural measures to turn baby before  If my primary care provider determines that a cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows.
Natural Induction
If induction is suggested, I will use natural techniques prior to procedure:
 Sexual Intercourse
 Nipple Stimulation
 Walking
 Spicy foods
 Herbs / Homeopathy
 Chiropractic
 Acupuncture / Acupressure / Shiatsu
 Hypnosis / Stress Reduction Techniques
If my baby is found to be in breech position at 37 weeks to term, I will use natural means to turn the baby before
scheduling a cesarean section:
 Chiropractic – look for Webster technique certification
 Acupuncture / Acupressure / Shiatsu
 Hypnosis / Stress Reduction Techniques
 Positions / swimming / additional tools
 External version as a last measure
If my baby is found to be in the OP or transverse position between 37 weeks and even during birth, I will use
natural means to turn the baby:
 Chiropractic for pelvic adjustment
 Acupuncture / Acupressure / Shiatsu
 Positions such as polar bear, hands & knees, lunges and supported child’s pose (up to 1 hour at a time before

Water Breaks – what to do
Sometimes your water may break and contractions do not start immediately - this does not
indicate a medical situation. For this reason, you do not need to go to the hospital as soon as your water breaks
(going early may increase your chances of unnecessary medical intervention.) Once the water breaks infection
becomes a reason for medical intervention; HOWEVER, infection is introduced by something entering the vagina
such as vaginal exams and sex. Refraining from having anything inserted into the vagina prevents infection.
Antibiotics may be requested as a first step after a reasonable amount of time has passed to allow contractions to
begin on their own, and as an option before moving to induction or softening agents such as misoprostol (cytotec)
or cervidil (Dinoprostone). Ideally you are given as much time as you need (anywhere from 24 up to 72 hours) in
the absence of medical urgency.
IF WATER IS DISCOLORED: meconium is present and you should call your provider.

 If my water breaks, the water is clear, and my contractions do not start immediately, I would like to be able to
wait 24 hours without intervention as long as the baby and I are medically sound.  After 24 hours, I prefer antibiotics to be introduced rather than other intervention.  I prefer continued wait after antibiotics are administered, as long as needed and while mother and baby are Options for Hospital Admittance and Procedures
 If I am less than five centimeters dilated and my water has broken, I would like the option of returning home
 Upon arrival at the hospital, I prefer to have my partner with me at all times
 Please, no residents or students attending my birth
Pain Scales
 I prefer not to participate in taking pain scales
 I would like to have a nurse who supports gentle birth – request upon admittance.
 I prefer to use all birth equipment available such as birth ball, peanut, tub, shower, birthing stool, squat bar
 I prefer to set my environment with low lights, music, soft voices, sign on the door
 Please keep my door always closed during labor
 I would like to wear my own clothes during labor and delivery
 I would like to have my birth photographed
 I would like to wear my glasses or contact lenses unless removal becomes medically necessary
 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.
 Use of shower and/or Jacuzzi; hydrotherapy

Stripping Membranes, Amniotomy, Breaking the Water
Sometimes doctors or midwives will perform a procedure without prior discussion, based on what they think is best
for her.
Ensure clear communication occurs at all times.
 Please obtain my permission before stripping my membranes, amniotomy or breaking my water during a  I prefer minimal internal vaginal exams or at my request only.  I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation)
IV, heplock or no IV prep
Upon hospital admittance, you have a choice of not having any IV, having a heplock placed (prep for IV) or being
placed on an IV. Drinking water can replace the need for IV in the absence of medical urgency. Consider how an
IV can restrict your movement while laboring and giving birth.
 I prefer to have no IV
 I prefer to have a heparin or saline lock
Monitoring Baby’s Heart Rate
Fluctuations in the baby’s heart rate are normal during labor and birth. Moving during labor and birth can be the
first course of action to regulate the baby’s heart rate, preventing the need for a medical procedure.
 I prefer the baby to be monitored intermittently
 If continuous monitoring is necessary, please use a wireless monitor
 Internal monitor only after changing positions to side-lying or hands and knees and verifying distress
If pitocin is recommended, you have some options before accepting that procedure…
 If induction becomes necessary, I would like to try walking, nipple stimulation, position changes first
 If induction becomes necessary I prefer to try stripping the membranes as the least aggressive first, moving to
 As a next measure, would like to have the amniotic membrane ruptured before other methods are used to  As a next measure, I prefer using a low dosage of pitocin, moving to a higher dosage incrementally if needed Cervical Ripening Agents
In the absence of medical urgency, Natural Induction (please see topic in first section) can be used prior to
introduction of cervical ripening agents. If these are being discussed for use after water breaks, please see “Water
Breaks – what to do” above for options such as antibiotics before introducing ripening agent.

Pain Medication: un-medicated and medication options
There are several options for pain management before moving to the full epidural. Be aware of your options and
how each will affect your labor at the time they are requested. This list offers the options you can move through
beginning with natural options and prior to full medication.
 Please only offer pain medications if I ask for them.
 First use un-medicated options as positions changes, hydrotherapy, warm compresses, manual pressure release
 Saline injections applied to site of discomfort
 Narcotic pain relief (Nubain, Demerol, Stadol or similar) starting with a half dose.
 I would like to have a walking epidural (low dose) and have it removed when I am ready to give birth.
 Full epidural
 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.
Things to consider regarding pain relief:
There are a range of options for pain relief. As listed above, you can ask for a shot of saline to be injected to dull
sensation, you can ask for narcotic shots aimed to taking the edge off of intense sensation, or for a walking
epidural, or a full epidural or spinal. Under what circumstances might you welcome any of these?
Things to think about:
o How long mom has been laboring, and her energy level; o Mom’s need for sleep or rest: can some pain relief help? o Allowing mom to regroup emotionally, or catch her breath? There is no right or wrong answer, and one size does not fit all.

Positioning, touch, and setting up a relaxing environment are keys to gentle birth. At the same time, each couple
can discuss ahead of time circumstances under which they would welcome medical intervention or pain relief.
 I would like to avoid catheterization unless absolutely necessary.
 I will ask for an enema if I feel that I need one.

Pushing / Mother-Directed breathing
Be aware of the differences between mother-directed breathing vs. valsalva pushing. Breathing with your body’s
movements can allow your body to work more effectively, especially when paired with re-positioning mother’s
body as needed.
 Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge
to push before beginning the birthing phase.  It's important to me to push instinctively and direct my breath effectively. I do not want to be told how or  As long as the baby and I are healthy, I prefer to have no time limits implemented on giving birth
 I prefer to try various positioning options to allow the contractions and my breathing to work more effectively.

Squatting using birth companion or squat bar  No stirrups please unless I'm having a medical emergency
 I do not wish to be tied down under any circumstances
Vacuum Extraction / Foreceps
 Before introducing the vacuum extractor or forceps, I would like to assume a different position to avoid

 I prefer not to have an episiotomy and risk tearing (only if medical emergency)
 Encourage me to breathe properly for slower crowning.
 Please use warm oil compresses during crowning.
 Notify me / birth partner prior to episiotomy procedure
 I prefer to change positions before resorting to episiotomy
 If I need an episiotomy, I prefer a pressure episiotomy (This procedure is done as the baby’s head is crowning
and the perineal tissues are slowly stretched. It usually allows for a smaller incision that heals better with less stitching.)
Crowning / Birth – procedural options
Ideally after the baby is born, there is adequate time given (ideally at least an hour) for the family to bond together
before the baby is handled for any medical procedures. During this time skin-to-skin can be initiated, breast crawl
or breastfeeding begins, the umbilical cord will stop pulsating and be cut (about 20 minutes), and the placenta will
be delivered (about 30 minutes). These and additional options are listed below.

Suctioning baby’s mouth and nose
Some parents do not want the baby to be suctioned as a standard procedure. Babies can be given the chance to
clear the mucus on their own before moving to suctioning. You can request that your baby not be suctioned while
on the perineum, or that s/he not be suctioned at all. Suctioning is invasive for the baby, and some believe that it
can interfere with breastfeeding. Some providers will insist on suctioning the baby if the amniotic fluid is stained
with meconium (baby’s first bowel movement). Even so, you can discuss this in advance and let your preferences
be known.

 Please do not suction my baby on the perineum (before baby is fully born)
 Please do not suction baby unless medically necessary (ie: when meconium is present)

Delayed Cord Clamping / Cutting the cord
Immediate cord clamping is part of the medical model of birth. However, delayed clamping, or waiting to clamp
and cut the cord until it has stopped pulsing, greatly benefits the baby and mother by:

Continuing to send blood and oxygen to the baby’s lungs until breathing established. Therefore, as the baby becomes acclimated or needs additional assistance while starting to breath on it’s own, delayed clamping of the cord acts as a safety net for the baby. As long as the cord is unclamped, the average transfusion of blood to the baby from the placenta counts for 21% of the baby’s final blood volume. Put another way, early clamping deprives baby of blood supply. o For babies born at term, this delaying the clamping increases their iron supply
o For preterm babies, delayed clamping is associated with reductions in anemia, bleeding in the
brain, and the need for transfusions. Making it easier for placenta to deliver without intervention (when the cord is clamped, blood cannot flow out of it; a blood-packed placenta stays firm and full and is less likely to separate on its own). Increasing the baby’s red blood cells by over 50% Even a few minutes of delayed cord clamping can make a significant difference to your baby.

 Please delay cord clamping after birth.
 Please delay cord clamping and do not cut the umbilical cord until pulsation has stopped.
 My partner will cut the cord after pulsation has stopped.
 I would like to bank my baby's cord blood and have made arrangements for this procedure prior to the birth. I
would like to discuss cord blood banking in conjunction with delayed cord clamping. Cleaning the baby – Vernix
Some couples do not want to have the vernix or amniotic fluid removed from the baby until they decide when it is
appropriate. The vernix is the white coating on the baby’s skin after birth – it serves to keep the baby’s skin
moisturized and the baby is also kept warm and free from any contaminants in the air. The fluids that are also on
the baby after birth act as a “road map” to the breast for breastfeeding and will aid in the Breast Crawl (next topic).
These fluids help to stimulate the crawling reflex, where the baby is able to navigate effectively on it’s own to the
breast without interference.

 Please do not wipe my baby down at all after birth.
 Please do not wipe my baby down after birth and until we have had time to bond.
 Please do not bathe my baby.
 We would like to give our baby its first bath. Please help direct us in this process at the hospital
Breast Crawl
After the baby is born, parents may allow their baby to crawl without assistance to the mother’s breast. Babies
have an innate crawling reflex that drives them to find the breast; ideally babies are not wiped down and have their
vernix/amniotic fluid removed as it helps the baby to “smell” it’s way to the nipple. The process may take about
15-20 minutes total and is typically done after an un-medicated birth while the mother is waiting to birth the
placenta. If this cannot be done after birth, the reflex is still active for up to six weeks after birth. Benefits are many
for mother and baby including natural latching and increased bonding especially after cesarean or challenging birth
experiences. See for more details.
 I prefer to have the baby crawl unassisted to my breast after birth.
Skin-to-Skin Bonding
Determine the importance of your bonding time as a new family. Procedures do not need to begin until at least
one hour after birth to allow the mother, partner and baby to fully bond.
Bonding can have a profoundly positive impact on the health of mother and baby and is strongly advised.
 I would like my baby placed immediately on my abdomen following the birth
 Please delay cord clamping and cutting until pulsation has stopped to allow the baby to receive it’s complete
 Please put my baby skin-to-skin on my abdomen with a warm blanket over it.  Please do not separate me from my baby for any reason other than medical  Please delay all essential routine procedures on my baby until after the bonding and breastfeeding time period
Placenta Delivery
Are you interested in natural placenta delivery or a medical delivery?
 I would prefer for the placenta to be born spontaneously without the routine use of pitocin, and/or manual
 I would like to hold the baby while I deliver the placenta and any tissue repairs are made.
 I would like to omit routine pitocin after the placenta is born unless there are any signs of hemorrhaging.
 Please allow my partner to cut the umbilical cord.
Placenta – Retaining for home use – natural, medical or cesarean birth
Some couples are interested in placenta encapsulation, which allows mother to take advantage of the medicinal
properties of the placenta for postpartum depression, hormone re-balancing, enhancing milk supply and increased
 I would like the option of taking home the placenta.
Cesarean Birth – Options for Planned and Emergency
Options are available to families who are planning a cesarean birth to make it more of a family experience for
mother, partner and baby, instead of being a “quick and easy procedure”. A story of the natural cesarean is here.

 If a cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making
 If a cesarean delivery is not an emergency, please give us time alone to think about it before asking for our  My partner(s) is (are) to be present at all times during the c-section.  Ideally, I would like to remain conscious during the procedure.  If possible, please discuss anesthesia options with me (including morphine options).  I would like to have music playing in the operating room.  Please respect my wishes to be quiet during the operation (e.g., avoiding "small talk" with other practitioners in  I wish to have the screen lowered for birth.  I would like to have the baby removed slowly allowing for the cord to continue pulsing before removal.  I would like the baby to be shown to me immediately after it's born.  I would like the baby to be placed on my skin immediately after birth.  I would like to sign any waivers necessary to permit me to be with my baby in recovery.  I would like to hold my baby and nurse it immediately in recovery.  I would like to incorporate the breast crawl in recovery (see Breast Crawl page 7).  Please provide lactation assistance if necessary in recovery.  If I cannot be free to bond with my baby, I would like my partner to be the baby's constant source of attention until I am able (i.e., holding, skin-to-skin contact, etc.).  I would like to have any catheter or IV removed immediately after my recovery period.
Procedures for Newborn
No matter what type of birth you are designing, you have several options for how your baby is handled after birth.
These options are considered with your baby’s best interest in mind.

 I plan to keep the baby near me following birth and would appreciate if the evaluation of the baby can be
done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation.  Please delay cord clamping and cutting until pulsation has stopped to allow the baby to receive its complete  If the baby has any problems, I would like my partner to be present with the baby at all times, if possible.
 I would like to have routine newborn procedures delayed until bonding and breastfeeding have occurred.
 I would like all newborn routine procedures to be performed in my presence.
In case of medical emergency, I would like to be transported with my baby if possible and … Breastfeed or express my milk for my baby. Have as much bodily contact with my baby as possible.
Erythromycin (eye drops)
 I would like to delay the administration of eye drops (erythromycin) up to two hours after birth.
 Please do not administer eye drops to my baby – I will sign a formal waiver if need be.
Immunization is a personal preference. Some parents prefer to have standard immunizations in the hospital, others
choose to stagger the medication and some do not choose to have all of the standard immunizations.
 I prefer to discuss immunizations prior to them being administered.
 I would like to have immunizations administered while baby is with mother or partner for comfort.
 I will wait to immunize my baby until after we leave the hospital.
PKU testing is done with a heel prick to determine blood anomalies in the baby. This test can also determine
whether the baby’s blood is clotting as it should (see Vitamin K).

 Routine PKU testing done while baby with mother or partner for comfort.
 We decline routine PKU testing at the hospital and have made other arrangements for this procedure at a later

Vitamin K
Vitamin K is administered to manage a potential clotting issue in the baby. Some parents wait to see if the PKU test
determines there is a clotting issue.
 I would like to delay the administration of vitamin K up to 2 hours after birth unless medically necessary.
 I would like only the orally administered vitamin K to be given to my baby
 Please do not administer vitamin K to my baby.

Circumcision is a choice. It is not medically necessary, and like any surgical procedure, it involves risk, including
the risk of hemorrhage. It does involve pain, both during the procedure, and afterward during recovery. Pain
during the procedure can be lessened with a local anesthetic. Pain after the procedure likely cannot be avoided.
Some people may have important cultural or religious reasons for circumcision. At the same time, some people
who do not have religious or cultural reasons for circumcising have sometimes felt pressured into it by conventions,
or in some cases, by hospital personnel who ask about circumcision as if it is routine or required. The choice is a
personal one, and it is yours to make.
As you think about whether circumcision is the right choice for your child, think about the values that brought you
to this birth class, and allow those values to guide your choices about circumcision. If you choose to circumcise
your child, consider what might make the procedure as gentle and loving as possible.

Do you want loved ones to be present? When would you like circumcision to be performed? Do you want a loved one to hold your child’s hand or body, or restrain him, as is the practice in a Bris? Do you want to nurse immediately afterward? Do you want to nurse him immediately beforehand? What can you do to be as loving and emotionally present for your child as possible during the procedure, and after it?
 Please do not circumcise our baby.
 Please fully inform me of hospital procedures for circumcision prior to procedure for consideration of our
 We understand we can have the procedure performed by our pediatrician (or other provider) at a later time  I would like to be present for the circumcision and provide comfort for him.
 Please use a local anesthetic
Feeding Baby

 My baby is to be exclusively breastfed.
 Please offer guidance on the issue of formula versus breastfeeding.
 I would like to combine breastfeeding and formula feeding.
 I would like to see a lactation consultant as soon as possible for further recommendations and guidance.
Rooming In / Nursery
Depending on the hospital, standards may vary when it comes to having your baby taken away from you to have
certain procedures performed or to “allow mother to rest”. In the absence of medical urgency, you can request
that all procedures be done in your room without having the baby removed from you for any length of time or that
baby remain with you continuously during mother’s hospital stay. You simply need to be aware of these options
and make the request that is most appropriate for you and your baby.
 I prefer full rooming in, with no separation, unless medically necessary.
 I prefer partial rooming in - having the baby sent to the nursery at night so that I can rest.
 If my baby must go to the nursery, I prefer my baby not receive any


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