Columbia Center Birth Preference Guide

Name:

Physician:

Due date:

My support people will be:
(first name and relationship)

Introduction

I realize that my birth preference guide is neither a contract nor a guarantee of an uncomplicated labor. The purpose of this guide is to introduce myself and to help you understand my preferences.

Introducing myself (and support partner, if desired):

Important wishes, issues, fears or concerns regarding mother or baby:

Please refer to Penny Simkin's "Pain Medications Preference Scale" (PDF document) as your guide to help complete this section.

Preferences for managing labor pain:

Preferences for Normal Labor and Birth

First stage of labor:
(positions, movement, comfort measures, and food and beverages)

Second stage:
(positioning and pushing efforts)

Third stage and first hours after birth:
(for mother and baby)

Preferences for Unexpected Labor Events

Induction and prolonged or complicated labor:

Cesarean birth:

Other concerns or preferences:

Preferences for Mom's Postpartum Care

I plan to breastfeed: Yes No Haven't decided

Concerns and questions about mom or baby care:

Feelings about visitors:

Controlling pain postpartum:

Educational needs:

Follow-up after discharge:

Anything else you wish to share:

Preferences for Newborn Baby's Care

Baby's name:

 
 
  Check here if baby name not yet decided.

Baby's physician:

Baby is breastfeeding: Yes No Haven't decided

Parents' concerns, issues, wishes and/or fears:

Parent preferences regarding newborn examinations and procedures:
(contact with baby and routine procedures)

Parent preferences regarding immunization:

Baby boy should be circumcised: Yes No Haven't decided

Preferences for Unexpected Problems for the Baby

Premature or baby requiring extra-special care: