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Birth Preferences
Sample II
Chart Format
This type of Birth Preferences list works exceedingly well when printed
on a colored index card. It will stand apart from the rest of
the
papers in your chart (in a good way).
As alway, get it signed.
It's just a piece of paper otherwise and unenforceable.
BIRTH PREFERENCES
We have prepared these Birth Preferences to help you understand our
philosophy
and the kind of care we hope to have for the birth of our
child. We expect, and trust, that our practitioner
will seek our opinion on all issues that may affect our birth
experience or that deviate from these preferences. We fully realize
that
emergencies can happen, and that in the case of an emergency, the Birth
Team will take the best steps for our family.
Environment
- Voices Low
- Lights Dimmed
- No IV/Heplock if Needed
- Vaginal Exams as Requested
- Full Mobility as Tolerated
- Provide Informed Consent Before
All Procedures
- No Students/Residents
- Videotaping As Allowed
- Food/Drink as Tolerated
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Pain Management
- Intermittent Monitoring
- Access to All Birthing Equipment -
ball, stool, kneeler, tub, squat bar, shower, etc.
- No Lamaze-type Prompts
- Keep Water Intact
- Self-Directed Pushing
- Delayed Cord Clamping Until
Pulsing Has Stopped
- Medications Only if Requested
- Prefer to Tear
- Pressure Episiotomy if Needed
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Emergencies
- Father to stay with Baby as Much
as Possible
- Prefer Forceps over Vacuum
Extraction
- Breastfeeding as Soon as Possible
- Spinal Preferred
- Insert Catheter after Anesthesia
- Remove IV and Catheter As Soon as
Possible
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Newborn Procedures
- Delay All Procedures as Long as
Possible
- Non-irritating Eye Ointment
- We Decline all Newborn
Vaccinations at This Time
- No Circumcision
- No Supplementation
- 24 Hour Rooming In
- Nurse Immediately
- Oral Vitamin K if Available
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We thank you for taking the time to go over these Birth Preferences,
and
appreciate your cooperation in getting our new family off to great
start!
Physician
Date
Mother
Date
Father
Date
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