Birth Preferences
Sample III

Bullet Point Format
This type of Birth Preferences sheet also works well when printed on a colored index card.  A Bullet point list works best in an uncompromising place of birth.  It's a down-and-dirty, non-negotiable list of your most important preferences.

As alway, get it signed.  Same reasons still apply.


We have prepared these Birth Preferences to help you understand our philosophy and the kind of care we hope to have for the birth of our child.  We expect, and trust, that our practitioner will seek our opinion on all issues that may affect our birth experience or that deviate from these preferences. We fully realize that emergencies can happen, and that in the case of an emergency, the Birth Team will take the best steps for our family.

  • Provide Informed Consent Before All Procedures
  • Full Mobility with Intermittent Fetal Monitoring
  • Self-Directed Pushing
  • Avoid all Labor Augmentation
  • Delayed Cord Clamping
  • Prefer Tear vs Episiotomy
  • Delay All Newborn Procedures
  • No Circumcision
  • We Refuse All Newborn Vaccinations
  • Breastmilk Only - No Supplementation of Any Kind
  • If Baby is Sick, Father will Accompany at All Times

We thank you for taking the time to go over these Birth Preferences, and appreciate your cooperation in getting our new family off to great start!

Physician        Date            Mother            Date            Father        Date