Full name
Partner’s name
Doctor’s name

Please note that the following apply to me:

  • GBS+
  • RH negative
  • Gestational diabetes
  • VBAC
  • Previous surgery

During labour I’d like:

  • To wear my own clothes
  • To wear the hospital clothes
  • Music played
  • The lights dimmed
  • My partner to take pictures
  • My partner to be present the entire time
  • To eat and drink as approved by my doctor
  • To stay hydrated with clear fluids and ice cubes
  • To have unlimited freedom to move, use the birth ball, sit on chair
  • As few interruptions as possible, and limit my visitors to only: (names)

I like foetal monitoring to be:

  • Continuous monitoring (external)
  • Intermittant
  • Performed only if baby is in distress

Catheterisation:

  • Avoid at all cost
  • Insertion acceptable after epidural
  • Only in emergency

For pain relief I’d like to use:

  • Nothing – as natural as possible
  • Massage
  • Epidural
  • TENS
  • Positioning
  • Pethidine and phenegan
  • Entonox gas
  • Relaxation techniques
  • Water (shower)
  • Birth ball
  • Only what I request at the time
  • Whatever I suggested at the time

Labour augmentation/induction:

  • No induction
  • No augmentation
  • Do not rupture membranes
  • Rupture of membranes is acceptable
  • Will accept vaginal tablet
  • Will accept the use of syntocinon

During delivery I would like to:

  • Bear down in the position I feel comfortable
  • Push spontaneously
  • Push as directed
  • Touch the head as it crowns
  • Avoid forceps usage
  • Avoid vacuum extraction
  • Use whatever methods my doctor deems necessary
  • Push without time limits, as long as the baby and I are not at risk

I would like an episiotomy:

  • Rather than risk a tear
  • Performed only as a last resort
  • Performed as my doctor deems necessary
  • Not performed, even if it means risking a tear

Immediately after delivery, I would like:

  • My partner to cut the umbilical cord
  • To do STEM CELL collection as pre-arranged by us
  • I agree on syntocinon injection IM after delivery
  • To keep the placenta for capsulation
  • I want to do skin to skin contact immidiately
  • I want to hold my baby while the placenta is delivered
  • If our baby can not be examined in my presence, I want my husband to be present
  • The umbilical cord to be cut only after it stops pulsating (unless we use stem cells)

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

  • My partner to remain with me
  • My partner to hold the baby as soon as possible
  • To breastfeed in the recovery room

In event of baby admitted to NICU:

  • I want my husband to accompany our baby to the unit
  • I want to initiate breastfeeding as soon as possible

I would like:

  • To breastfeed exclusively
  • To formula feed excusively
  • To meet the breastfeeding consultant
  • Baby’s first bath given in my presence
  • Baby’s medical exam and procedures given in my presence
  • Baby to stay in my room at all times
  • A circumcision if we have a boy
  • My baby to receive Vit K
  • My baby to receive Hep B and BCG
  • My baby to have a blood screening test