Intro General Info Birth Philosophy During Labor Anesthesia Preparation & Equipment 2nd Stage of Labor Delivery Cesarean Section 3rd Stage of Labor Postpartum Infant Feeding Circumcision My Hospital Stay Additional Notes Save/Print Tuesday, March 28, 2023 My Birth Preferences At West Valley Medical Center, we’re dedicated to providing you and your family with focused attention and compassionate care as you go through the journey of delivering a healthy baby. We created this tool to help you outline some of your preferences for the childbirth process. Situations may arise during which – for the safety of you or your baby – your first preference is not possible. If those situations arise, you will be kept informed of your choices and allowed the chance to give informed consent whenever possible. We’ll partner with you to reach your labor and delivery goals together in a safe, nurturing environment. Please save this document for your own records, bring it to your free Childbirth Preparation Class, share it with your provider, and tuck a copy in your “go bag” for the big day! General Information First Name Last Name Phone Number Partner's Name Primary Care Doctor OB-GYN Due Date or Induction Date Birth Philosophy What would you like us to know about you and/or your support person? What is your greatest hope and/or greatest concern about labor and delivery? During Labor I would like coaching and encouragement throughout labor. Other I would like the following parties present during: Labor Vaginal Exams Delivery During labor, I would also like The option to wear my personal clothing To listen to music before birth To listen to music during birth The lights dimmed The room as quiet as possible To eat and drink as approved by my doctor I would like to be able to walk around, mobility is important to me. I would prefer a warm bath if I don’t feel up to walking. My partner to take pictures Other Anesthesia/Pain Medication For pain relief, I’d like to use Breathing techniques IV Pain medication Standard epidural I would like to keep my options open for an epidural, but my goal is an unmedicated delivery. I would like a natural birth if possible I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor. Please only offer pain medications if I ask for them. 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. Other Preparation/Equipment I would like the following equipment available to me. Birthing ball Squatting bar Other 2nd Stage of Labor I would like counting to help me push. I would like a squat or birth bar to aid in pushing I prefer foot pedals to allow me to sit up while pushing I prefer stirrups to allow me to lay back during pushing I prefer my support person to support my legs when pushing I wish to be able to move and change positions throughout my labor Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase Please encourage me to breathe properly for slower crowning Unless necessary for the safety of my baby, I do not want forceps or a vacuum extractor Other Delivery I would like a mirror available so I can see the baby's head when it crowns I would like the chance to touch the baby's head when it crowns I would like to catch my baby and pull it onto my abdomen as it is born 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 for an hour Other Cesarean Section Delivery If a C-section is necessary, I would like To stay conscious if possible My hands left free so I can touch the baby after birth My partner to hold the baby as soon as possible Skin-to-skin contact after delivery To breastfeed my baby as soon as possible Other 3rd Stage of Labor Immediately after delivery, I would like To cut the cord myself For my partner to cut the cord The umbilical cord to be cut only after it stops pulsating To keep the placenta. I understand I will be responsible for removing it promptly to a private refrigerator. To see the placenta before it is discarded Skin-to-skin contact while I deliver the placenta and any tissue repairs are made Other Postpartum I would like to hold the baby Immediately after delivery After weighing After being wiped clean and swaddled Before eye drops/ointment are given Other Please give the baby Vitamin K Antibiotic eye treatment Sugar water for comfort, as needed Pacifier Other Whenever possible post-delivery, I would like To not be separated from my baby My partner to accompany the baby if the baby must be taken from me to receive medical treatment To have the baby's first bath and assessment done in my presence Other As needed post-delivery, please give me Extra-strength acetaminophen Narcotic pain medications as needed Stool softener Laxative Ibuprofen to treat uterine cramping pain Other If baby is not well, I’d like My partner and I to accompany it to the NICU or another facility To hold him or her whenever possible Other Infant Feeding I’d like to feed my baby Only with breastmilk Only with formula With breastmilk and formula Using pumped breast milk With the help of a lactation specialist Other I would like to breastfeed As soon as possible after delivery Before eye drops/ointment are given Other Circumcision I do not want to have my baby circumcised I would like more information about circumcision Other My Hospital Stay For my hospital stay, I would like For my support person to stay in the room with me My baby in the room with me as much as possible To use my own blanket and pillow To bring books and magazines to read Other Additional Notes Additional Notes Save My Birth Preferences Save By selecting the Save button, your information will remain available for two days. If this is a public computer, we don't recommend saving this form. Print You may also print out your birth preferences to have on hand during your pregnancy. Please consider the environment before printing. Reset By selecting the Reset button, your information will be cleared from all the above fields. Next Steps Once you complete your birth plan, we recommend the following next steps: Contact us to find out about tour options and maternity classes Print and discuss the birth plan with your doctor Bring a printed copy of the birth plan with you when you come to deliver at the hospital General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)
Tuesday, March 28, 2023 My Birth Preferences At West Valley Medical Center, we’re dedicated to providing you and your family with focused attention and compassionate care as you go through the journey of delivering a healthy baby. We created this tool to help you outline some of your preferences for the childbirth process. Situations may arise during which – for the safety of you or your baby – your first preference is not possible. If those situations arise, you will be kept informed of your choices and allowed the chance to give informed consent whenever possible. We’ll partner with you to reach your labor and delivery goals together in a safe, nurturing environment. Please save this document for your own records, bring it to your free Childbirth Preparation Class, share it with your provider, and tuck a copy in your “go bag” for the big day! General Information First Name Last Name Phone Number Partner's Name Primary Care Doctor OB-GYN Due Date or Induction Date Birth Philosophy What would you like us to know about you and/or your support person? What is your greatest hope and/or greatest concern about labor and delivery? During Labor I would like coaching and encouragement throughout labor. Other I would like the following parties present during: Labor Vaginal Exams Delivery During labor, I would also like The option to wear my personal clothing To listen to music before birth To listen to music during birth The lights dimmed The room as quiet as possible To eat and drink as approved by my doctor I would like to be able to walk around, mobility is important to me. I would prefer a warm bath if I don’t feel up to walking. My partner to take pictures Other Anesthesia/Pain Medication For pain relief, I’d like to use Breathing techniques IV Pain medication Standard epidural I would like to keep my options open for an epidural, but my goal is an unmedicated delivery. I would like a natural birth if possible I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor. Please only offer pain medications if I ask for them. 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. Other Preparation/Equipment I would like the following equipment available to me. Birthing ball Squatting bar Other 2nd Stage of Labor I would like counting to help me push. I would like a squat or birth bar to aid in pushing I prefer foot pedals to allow me to sit up while pushing I prefer stirrups to allow me to lay back during pushing I prefer my support person to support my legs when pushing I wish to be able to move and change positions throughout my labor Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase Please encourage me to breathe properly for slower crowning Unless necessary for the safety of my baby, I do not want forceps or a vacuum extractor Other Delivery I would like a mirror available so I can see the baby's head when it crowns I would like the chance to touch the baby's head when it crowns I would like to catch my baby and pull it onto my abdomen as it is born 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 for an hour Other Cesarean Section Delivery If a C-section is necessary, I would like To stay conscious if possible My hands left free so I can touch the baby after birth My partner to hold the baby as soon as possible Skin-to-skin contact after delivery To breastfeed my baby as soon as possible Other 3rd Stage of Labor Immediately after delivery, I would like To cut the cord myself For my partner to cut the cord The umbilical cord to be cut only after it stops pulsating To keep the placenta. I understand I will be responsible for removing it promptly to a private refrigerator. To see the placenta before it is discarded Skin-to-skin contact while I deliver the placenta and any tissue repairs are made Other Postpartum I would like to hold the baby Immediately after delivery After weighing After being wiped clean and swaddled Before eye drops/ointment are given Other Please give the baby Vitamin K Antibiotic eye treatment Sugar water for comfort, as needed Pacifier Other Whenever possible post-delivery, I would like To not be separated from my baby My partner to accompany the baby if the baby must be taken from me to receive medical treatment To have the baby's first bath and assessment done in my presence Other As needed post-delivery, please give me Extra-strength acetaminophen Narcotic pain medications as needed Stool softener Laxative Ibuprofen to treat uterine cramping pain Other If baby is not well, I’d like My partner and I to accompany it to the NICU or another facility To hold him or her whenever possible Other Infant Feeding I’d like to feed my baby Only with breastmilk Only with formula With breastmilk and formula Using pumped breast milk With the help of a lactation specialist Other I would like to breastfeed As soon as possible after delivery Before eye drops/ointment are given Other Circumcision I do not want to have my baby circumcised I would like more information about circumcision Other My Hospital Stay For my hospital stay, I would like For my support person to stay in the room with me My baby in the room with me as much as possible To use my own blanket and pillow To bring books and magazines to read Other Additional Notes Additional Notes Save My Birth Preferences Save By selecting the Save button, your information will remain available for two days. If this is a public computer, we don't recommend saving this form. Print You may also print out your birth preferences to have on hand during your pregnancy. Please consider the environment before printing. Reset By selecting the Reset button, your information will be cleared from all the above fields. Next Steps Once you complete your birth plan, we recommend the following next steps: Contact us to find out about tour options and maternity classes Print and discuss the birth plan with your doctor Bring a printed copy of the birth plan with you when you come to deliver at the hospital General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)