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My name: __________ Due date: __________ Midwife: __________
Who is with me
- Partner: __________
- Doula: __________
- Other support: __________
- Children present: Yes / No
My environment
- Dim lights
- Music: __________
- Birth pool
- Quiet voices
- Photos or video: Yes / No
Comfort in labor
- Movement and position changes
- Water
- Massage and counter-pressure
- Heat or cold packs
- Rebozo
- Other: __________
Pushing and birth
- Positions I would like to try: __________
- I would like to touch my baby's head: Yes / No
- Who announces the baby's sex: __________
Right after birth
- Baby placed on me right away
- Delayed cord clamping
- Cord cut by: __________
- Uninterrupted first hour
Newborn care (discuss with your midwife)
- Vitamin K: Yes / No / Discuss
- Eye ointment: Yes / No / Discuss
- Newborn screening timing: __________
Feeding
- Breastfeeding
- Formula
- Combination
If plans change
- What matters most to me: __________
- Who should be with me: __________
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This content is for general education and is not a substitute for individualized medical care. Always talk with your midwife or health care provider about your situation. If you are experiencing an emergency, call 911.
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