Birth Preference Builder

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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 *

Husband / Partner Name (if applicable) *

Please enter the product number

Telephone Number

Email address *

Estimated Due Date *

YYYY

What type of birth do you envision?

Vaginal Birth

Natural Birth (without medication or unnecessary interventions)

Epidural for Labor and Birth

Cesarean Birth

Induction of Labor

Other:

Where are you planning to deliver? With whom? *

Please rate the following and this is under the premise that there is NO MEDICAL reason, what is your preference?

Mobility

I would like to maintain mobility throughout labor.

I do not plan to stay mobile throughout labor.

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Vaginal Exams

I would prefer to avoid Vaginal Exams throughout labor and birth.

I would be ok with Vaginal Exams at a minimum.

I am ok with Vaginal Exams

IV During Labor

I would prefer to avoid an IV during labor.

I would be ok with an IV during labor, just not upon admission.

I am ok with having an IV throughout labor.

I would prefer to have only a Saline Loc during labor.

Wearing a gown provided by the hospital

I plan to labor and birth in my own clothes.

I would prefer to wear a hospital gown during labor and birth.

External Monitoring

I would prefer to have Intermittent monitoring throughout labor and birth.

I would be ok with Continuous monitoring throughout labor and birth.

Internal Fetal Scalp Monitoring

I would prefer to avoid Internal Fetal Scalp monitoring unless truly medically necessary.

I would be ok with Internal Fetal Scalp monitoring.

Artificial Rupture of Membranes (breaking your bag of waters for you)

I would prefer to avoid having my membranes stripped and/or ruptured artificially.

I would be ok with having my membranes ruptured, as a last resort.

I am fine with having my membranes stripped.

Induction of Labor (after 41 weeks)

I would prefer to avoid an Induction after 41 weeks.

I would be ok with an Induction after 41 weeks, as a last resort.

I am ok with an Induction after 41 weeks.

Induction of Labor (prior to 41 weeks)

I would prefer to avoid an Induction prior to 41 weeks.

I would be ok with and Induction prior to 41 weeks, as a last resort.

I am ok with and Induction prior to 41 weeks.

Epidural for Labor

I would prefer to avoid an Epidural, I will ask for it if I need it.

I would prefer to have an Epidural prior to 6 cm.

I would prefer to have an Epidural after 6 cm.

Narcotics for Labor

I would prefer to avoid an all Narcotics for labor and birth.

I would prefer Narcotics in labor vs having an Epidural.

Pitocin Augmentation

I would prefer to avoid having my labor Augmented unless medically necessary.

I would be ok with having my labor Augmented.

Pitocin After Delivery

I would prefer to avoid Pitocin after delivery unless medically necessary.

I would be ok with Pitocin after delivery.

Urinary Catheter

I would prefer to avoid having a Urinary Catheter.

I would be ok with having a Urinary Catheter, IF I get an Epidural.

Vacuum Assisted Birth

I would prefer to avoid having baby born by Vacuum.

I would be ok with baby born by Vacuum if medically necessary.

Forceps Assisted Birth

I would prefer to avoid having baby born by Forceps.

I would be ok with baby born by Forceps if medically necessary.

Perineal Tear

I would prefer to avoid tearing, being off my back and guidance with pushing would be very helpful.

I would be ok if I tore naturally.

Episiotomy

I would prefer to avoid an Episiotomy.

I would be ok with an Episiotomy, only if medically necessary.

I am ok with having an Episiotomy.

Breath holding during pushing

I would prefer to avoid holding my breath during pushing (or purple pushing).

I would be ok with holding my breath during pushing and guidance with pushing.

Delivering on your back

I would prefer not to be on my back during delivery (my side or upright is preferred).

I would be ok with being on my back for delivery.

Counting during pushing

I would prefer that my coach and Nurses not count during pushing.

It would be helpful if my coach and Nurses counted during pushing.

Cesarean Birth

I would like to avoid a Cesarean and that it be done only if medically necessary.

I have a scheduled Cesarean planned.

What is your preference for your New Baby/Babies?

Suctioning Baby

I would prefer that baby be suctioned only if medically necessary.

I would be ok with my baby being suctioned at birth.

Vigorous Rubbing (removing vernix)

Please avoid vigorous rubbing or removing of the vernix.

Gentle rubbing immediately after birth is ok.

Please wipe all of the vernix off immediately.

Delayed Cord Clamping

Please postpone clamping and cutting of the cord until it stops pulsating.

Please wait 3-5 minutes before clamping and cutting of the cord.

I'm fine with clamping and cutting of the cord right away.

Cord Blood Banking

We will be banking babies cord blood and have our kit ready.

We will NOT be banking babies cord blood.

Vitamin K injection

I would like my baby to received the Vitamin K Injection right away.

I would like to wait until breastfeeding is established before administering Vitamin K Injection.

I would prefer to avoid the Vitamin K Injection.

We will be bringing Oral Vitamin K from our Pediatrician.

Eye Ointment

I would like my baby to received the Eye Ointment right away.

I would like to wait until breastfeeding is established before administering the Eye Ointment.

I would prefer to avoid the Eye Ointment.

Breastfeeding / Chestfeeding

I plan to exclusively breastfeed / chestfeed my baby, no artificial nipples or pacifiers.

I do NOT plan to breastfeed / chestfeed by baby.

Donor Milk will be provided.

Circumcision

I plan to have my son Circumcised.

I do NOT plan to have my son Circumcised.

Hepatitis B Vaccine

I would prefer to avoid the Hepatitis B vaccine.

I would prefer to have the Hepatitis B vaccine.

I plan to discuss the Hepatitis B vaccine with my Pediatrician at our office visit.

Placenta

I would prefer that my placenta NOT be sent to pathology, I plan to take it home.

I do not have plans for my placenta.

Bathing Baby

I would prefer that my baby not receive a bath while in the hospital.

I would prefer the Nurses show us how to bathe baby.

I would like my baby bathed soon after birth.

How can we best support you during your stay?(please be specific)

How can we best support your husband/partner or other support person? (please be specific)

What are your expectations during your labor, birth and postpartum stay?

Do you have a Doula for your birth? If so, who? If not, would you like a referral?

Do you plan to take a Childbirth Class? If so, with whom and when?

Do you plan to take a Breastfeeding / Chestfeeding Class? If so, with whom and when?

Would you like to be contacted by Rená Koerner for individualized guidance?

Yes

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