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