My Preferences for Labor, Birth, and Postpartum Experience

Submit the completed birth preferences form to your healthcare provider during a prenatal visit. Ensure they review and discuss any potential changes with you. If required, you can also submit the form electronically via email or an online submission portal, or physically hand it over when you arrive at the hospital.

Ensure your birth plan is completed and discussed with your provider by the beginning of your third trimester. Update any changes to your preferences as needed before your due date.

The purpose of this form is to document the birth preferences of an expectant mother and guide the care team during labor, birth, and postpartum. By outlining choices for pain management, labor support, and newborn care, it ensures that the mother's values and desires are respected. This form also facilitates clear communication between the mother and her healthcare providers, contributing to a safe and personalized birth experience.

• 1. Personal Information: Includes fields for name, physician, date of birth, due date, and pediatrician/family doctor.
• 2. Labor Support Team: Identifies individuals who will be present during labor, such as partner, doula, friends, or relatives.
• 3. Environment Preferences: Options for the labor environment, such as lighting, music, and room ambiance.
• 4. Preferences for Monitoring the Baby: Choices for monitoring the baby's heart rate, including intermittent and continuous monitoring.
• 5. Preferences for Cervical Examination: Preferences for the number of cervical exams during labor.
• 6. Preferences for Food and Fluids: Options for hydration and food intake during labor.
• 7. Labor Preferences: Details about preferred movement, interventions, and procedures during labor.
• 8. Preferences for Managing Pain: Options for pain relief, including non-medical and medical methods.
• 9. Birth Preferences: Preferences for pushing, cutting the umbilical cord, and other birth-related choices.
• 10. Cesarean Birth Preferences: Choices for cesarean birth scenarios, including partner presence and skin-to-skin contact.
• 11. Newborn Care Preferences: Options for newborn procedures, breastfeeding, and circumcision.
• 12. After Delivery Preferences: Preferences for the postpartum period, including discharge timing and medication.
• 13. Additional Preferences: Space to include any other specific preferences, concerns, or cultural practices.

Failure to submit this form may result in your wishes and preferences not being communicated to your care team. This can affect the quality of care and your birth experience.

• Uncommunicated Preferences: Your specific wishes for labor and birth may not be known to your healthcare providers.
• Increased Stress: Uncertainty about care can lead to increased stress during labor and birth.
• Potential Safety Issues: Without a clear plan, there may be safety concerns for you and your baby if emergency decisions need to be made.

• 1. Planning Birth Preferences: Helps you outline and clarify your birth preferences.
• 2. Prenatal Visits: Discuss the form with your provider during prenatal visits to ensure they understand and respect your wishes.
• 3. Labor and Delivery: Provide the completed form to your care team when you arrive at the hospital.
• 4. Postpartum Care: Ensure your postpartum preferences are communicated and followed after delivery.
• 5. Emergency Situations: Having a documented plan allows for quick decision-making and clarity in emergency scenarios.