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Our Birth Preferences

Our names are XYZ
Our Doula’s name is Kelly

We’re hoping for a natural childbirth without unnecessary interventions or the use of drugs. We have asked a Doula to be present at the birth to help us work towards this. We appreciate your support with our birth preferences.

This plan represents our preferences; however we recognise that in the event of unforeseen difficulties it may need to be re-negotiated. Please discuss all options with us, in the presence of our Doula. We would then like the opportunity to contemplate our options without the presence of any medical staff. We would like the birth experience to be respectful and private as we know this is conducive to a successful birth, with minimal interruptions, quiet voices and dimmed lighting. I will be relying on DH and Kelly to provide the atmosphere we desire with the following aides for pain relief:

 I’d like to have dimmed lighting during the labour and birth
 I would like to use aromatherapy
 I would appreciate limited intervention, interruptions and quiet voices
 I’d like to have an active labour with the freedom to choose positions, use the shower or bath and walk around in labour as desired.
 I would like to use water as a form of pain relief, a shower or bath
 I would also like to use massage as a form of pain relief
 I’d like to be free to use movement and my choice of birthing position ie: not lying on the bed unless decided by me

MEDICAL INTERVENTION
 I’m happy to have continuous EFM. However, I will at any time take it off if I decide to shower/bath/move around and will do so at my own discretion.
 If IFM is deemed necessary I wish to obtain a second opinion.
 I prefer to tear than to have an episiotomy. I’d only like an episiotomy if there is a genuine medical emergency. Please allow time for the perineum to stretch naturally and I would like warm compresses used to assist with this.
 I have severe back pain if I lie flat on my back and do not want any unnecessary vaginal exams. I do not want them 4 hourly. If a VE is required I would like to be seated, kneeling or standing. Please discuss any need for a VE with us.
 I do not want a cannula placed in my arm/hand during labour
 I will eat/drink as I feel the need during my labour.
 No time limits to be placed upon us.

BIRTH AND SOON AFTER

Presuming baby and I are well, we’d like:

 For my husband to ‘catch’ our baby if he would like to
 To wait until the umbilical cord stops pulsating before clamping, to allow my baby to receive the valuable blood and iron stores.
 For DH to cut the cord once it has stopped pulsating.
 Not to have the routine Syntocinon injection to help deliver the placenta until after the cord has stopped pulsating and if medically required.
 To hold and feed our baby immediately after the birth
 For all newborn procedures (weighing and measuring) to wait until I have had time to bond with and breastfeed our baby
 For baby to be given only breastmilk – strictly no water or formula.
 We have chosen to defer Hepatitis B injections until baby’s first vaccinations at 2 mths.

CAESAREAN

If a caesarean becomes necessary I’d like:

 To wait until I am at least 14 days overdue prior to this being booked in. I am happy to have monitoring leading to this time.
 For DH to be with me. We’d also like to have our Doula Kelly with us to help enhance our experience of birth, no matter what form it takes
 For discussion to be respectful and minimal - only what is required medically and to inform me of what is happening
 Unless prevented by medical emergency, I would like my baby to be placed on my chest while you complete the procedure
 To be sure that a double layer suture is used and not a single layer in order to improve my chances for a future VBAC
 The opportunity to breastfeed our baby in recovery. If you do not have the staff to enable this, I wish to have my Doula with me so I can breastfeed in recovery.


Please sign our birth preferences in good faith that it has been read, will be treated respectfully and that we have your support in all of the above.

________________________________ Signed

________________________________ Name ______________ Date