Birth Preferences
Sample II

Chart Format
This type of Birth Preferences list works exceedingly well when printed on a colored index card.  It will stand apart from the rest of the papers in your chart (in a good way).

As alway, get it signed.  It's just a piece of paper otherwise and unenforceable.


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.

  • Voices Low
  • Lights Dimmed
  • No IV/Heplock if Needed
  • Vaginal Exams as Requested
  • Full Mobility as Tolerated
  • Provide Informed Consent Before All Procedures
  • No Students/Residents
  • Videotaping As Allowed
  • Food/Drink as Tolerated
Pain Management
  • Intermittent Monitoring
  • Access to All Birthing Equipment - ball, stool, kneeler, tub, squat bar, shower, etc.
  • No Lamaze-type Prompts
  • Keep Water Intact
  • Self-Directed Pushing
  • Delayed Cord Clamping Until Pulsing Has Stopped
  • Medications Only if Requested
  • Prefer to Tear
  • Pressure Episiotomy if Needed
  • Father to stay with Baby as Much as Possible
  • Prefer Forceps over Vacuum Extraction
  • Breastfeeding as Soon as Possible
  • Spinal Preferred
  • Insert Catheter after Anesthesia
  • Remove IV and Catheter As Soon as Possible
Newborn Procedures
  • Delay All Procedures as Long as Possible
  • Non-irritating Eye Ointment
  • We Decline all Newborn Vaccinations at This Time
  • No Circumcision
  • No Supplementation
  • 24 Hour Rooming In
  • Nurse Immediately
  • Oral Vitamin K if Available

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