At the top is listed the name of the family, the hospital and the doula
We trust the advice of our midwife and understand that certain emergency or other medical circumstances may not allow for the accommodation of the goals listed below.
We would like to labor at home as long as possible, with our doula present, before going to the hospital.
- We plan to have present at the birth and or labor: Midwife Name, Father Name, Doula Name. We ask that all other visitors and unnecessary staff be turned away until we (the parents) have had time alone with our new baby.
- We ask that lights be kept dim, noise be kept to a minimum, the door be kept closed for privacy.
- We will bring our own music.
- The mother may wish to wear her own clothing, although the staff may offer her a hospital gown.
- We appreciated your encouragment to be up out of bed as much as possible during labor.
- We are attempting to have a natural, un-medicated birth without unnecessary intervention.
- We understand that there are procedures which may become necessary.
- Except in the case of an emergency, we understand we will be given the opportunity to accept or refuse any procedure or medication. We understand the least invasive or restricting versions of procedures be offered first.
- We plan to handle pain with relaxation, massage and water (shower or tub).
- The mother would like to push at he own pace.
- The mother prefers to try perineal massage, support and warm compresses.
- If labor or delivery seems stalled, please encourage us to try different positions (hands and knees, squatting, birth stools, etc.).
- We would like to have the baby placed on the mother’s chest with skin-to-skin contact immediately after the birth and for the first 1 to 2 hours following the birth.
- We would like to be encouraged to have the baby breastfeed as soon as possible.
- We welcome the assistance of staff if necessary to facilitate breastfeeding.
- We would like the father and the doula to be allowed to take photos or video tape parts of the labor and birth.
- Please offer the father the opportunity to cut the cord.
Newborn Care Goals
- Please delay the eye medication and vitamin K shot as long as possible before leaving the labor and delivery room.
- We would like to be present at the baby’s first bath.
- We would like to have a set of footprints stamped into our scrapbook when footprints are done.
- We would like at least one parent to be present at the circumcision.
- The father would like to be present, but may need encouragement.
- We appreciate assistance breastfeeding immediately or as soon as possible afterward in the recovery room.
- We prefer the baby and father remain in the recovery room with the mother.
- We prefer to have a private room, if available, and that the father and baby be allowed to room-in.
- We prefer that our stay at the hospital be extended to the longest our insurance will allow so that the mother may recover as fully as possible before returning home.