Birth Preferences

Name *
Estimated Due Date *
Estimated Due Date
Please list your previous birth experiences and any vital information- dates, names, birth weights, etc. How did you labor begin? Approximately how long was your labor?
Have you had any complications in previous births? What coping strategies/pain relief did you use- which worked and which weren't helpful to you?
Have you taken or are you planning to take any childbirth education classes?
Select the statement that most accurately describes your wishes.
To whom do you tend to turn to for support during stressful or difficult times? How do they best support you in these moments?
Birth Attendants
Who will be with you at your birth?
If you are expecting others to be present at your birth, what role(s) do you want them to play?
Have you informed your care provider that you are hiring labor support?
Do you have a list of birth preferences or a birth plan?
Please indicate your feeling on the following statements.
I trust my care provider(s) 100%.
I prefer to limit medical induction such as cervical ripening agents, pitocin, etc.
I plan to have an epidural.
Mobility is important to me during labor.
I prefer to drink liquid instead of receive IV fluids.
I am interested in pain management and coping strategies before medicinal pain relief.
What else would you like us to know about you or your hopes/expectations for your birth experience?