Birth Preference Builder
This tool is designed to help you build your birth plan as you prepare for the big day.

As you proceed keep in mind that this is how you envision your birth, provided there is no medical reason. You will then get a one page summary of your answers in a .pdf that you can just print and take with you. CONGRATULATIONS in advance.

First and Last Name *
Your answer
Husband / Partner Name (if applicable) *
Please enter the product number
Your answer
Telephone Number
Your answer
Email address *
Your answer
Estimated Due Date *
MM
/
DD
/
YYYY
What type of birth do you envision?
Where are you planning to deliver? With whom? *
Your answer
Please rate the following and this is under the premise that there is NO MEDICAL reason, what is your preference?
Mobility
Vaginal Exams
IV During Labor
Wearing a gown provided by the hospital
External Monitoring
Internal Fetal Scalp Monitoring
Artificial Rupture of Membranes (breaking your bag of waters for you)
Induction of Labor (after 41 weeks)
Induction of Labor (prior to 41 weeks)
Epidural for Labor
Narcotics for Labor
Pitocin Augmentation
Pitocin After Delivery
Urinary Catheter
Vacuum Assisted Birth
Forceps Assisted Birth
Perineal Tear
Episiotomy
Breath holding during pushing
Delivering on your back
Counting during pushing
Cesarean Birth
What is your preference for your New Baby/Babies?
Suctioning Baby
Vigorous Rubbing (removing vernix)
Delayed Cord Clamping
Cord Blood Banking
Vitamin K injection
Eye Ointment
Breastfeeding / Chestfeeding
Circumcision
Hepatitis B Vaccine
Placenta
Bathing Baby
How can we best support you during your stay?(please be specific)
Your answer
How can we best support your husband/partner or other support person? (please be specific)
Your answer
What are your expectations during your labor, birth and postpartum stay?
Your answer
Do you have a Doula for your birth? If so, who? If not, would you like a referral?
Your answer
Do you plan to take a Childbirth Class? If so, with whom and when?
Your answer
Do you plan to take a Breastfeeding / Chestfeeding Class? If so, with whom and when?
Your answer
Would you like to be contacted by RenĂ¡ Koerner for individualized guidance?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms