I just finished mine, after a few re-writes with my doula. It was much longer, but we felt it was important to be able to give them one page (front and back). We're having a hospital birth, although I wish we were having a homebirth. I've omitted the identifying info. Also, it doesn't contain any requests about breastfeeding or rooming in, because that's pretty standard at our hospital (as is early discharge after birth). It's a cut and paste, so I apologize if the formatting is wonky!
This will be a VBAC. I look forward to working with nurses and doctors who truly believe in VBAC, and who will help us to achieve the most natural birth possible for our baby. We strongly wish that any medical procedures be discussed with us in advance so that we can make informed decisions. We thank you in advance for your support and wisdom. (my doula suggested adding this...sucking up never hurts, I guess!)
IMPORTANT NOTE: I am a survivor of a sexual assault, and experienced flashbacks during my daughter’s birth that may have contributed to my labour stalling. Privacy and feeling safe and in control will be VERY important to me during this birth. I thank you for your understanding and cooperation.
Present for the labour and birth: I request that as few people as possible be in the room at any given time during labour and the birth. I do NOT wish any students to be involved in the labour and birth.
Environment: We will be using a variety of natural relaxation and pain management techniques, including hypnosis. To assist us in this process, I require that my environment has dimmed lights and that voices are respectfully lowered at all times. Please do not ask me a question during a contraction. Please knock lightly on the door before entering.
Labour: I prefer to allow labor to begin spontaneously and to progress without augmentation once it has started. I would like labour to be allowed to proceed at its natural pace, no time restrictions placed on any stage.
I do not want induction or augmentation by means of Pitocin or any other synthetic hormone. I will not consent at any time to the use of Cytotec.
I prefer that my membranes rupture on their own. In the event that the baby is posterior, I would definitely like to avoid AROM until baby has rotated to anterior.
Since mobility is extremely important to me, I request intermittent monitoring using a Doppler. I request that the number of internal exams be kept to a minimum.
Pain management:PLEASE DON’T OFFER ME PAIN MEDICATIONS OR SUGGEST THAT I NEED THEM, including an epidural. In particular, I do not want to use narcotics. If I feel I need medication to deal with pain, I will ask for nitronox.
In addition to hypnosis, we will use the following as tools: breathing/relaxation, music, use of the shower/tub, walking, birthing ball, massage, and position changes.
Second Stage:I request quiet coaching during the second stage. No loud cheerleading or counting, please.
As long as it is clear that my baby's heart tones are good and that s/he is receiving sufficient oxygen, I would like to be free of time limits on pushing.
I wish to avoid an episiotomy, and would prefer to tear naturally if it seems unavoidable. I request care of the perineum to prevent or minimize tearing, to include the use of warm compresses and controlled pushing.
Andrew does not want to cut the cord, but we ask that he be the one to announce the sex of the baby.
We ask that the cord not be cut until it stops pulsating.
Third Stage: I wish to receive a local anesthetic for perineal suturing if necessary.
Postpartum: I wish to have the baby placed on my abdomen immediately following birth.
Please postpone Vitamin K and eye medication until after the initial hour of quiet alertness and parental bonding is established.
I’d like to breastfeed as soon as baby is ready.
Cesarean Delivery: I REQUEST A SECOND OPINION BEFORE CONSENTING TO A C-SECTION.
I prefer anesthesia by epidural/spinal ONLY, with a general to be used only in the most dire of emergencies.
I do not wish to be given any medication via IV or epidural that will alter the baby’s or my alertness. This includes the use of any medication typically given to ‘help the mother rest’ after surgery.
My husband and doula are to be present during surgery.
Please remove my IV and catheter as soon as possible following my baby’s birth.
Please provide me with nutritious food and drink as soon as possible.
If the baby must be taken to the special care nursery, Andrew will accompany him/her.
I’d like skin-to-skin contact and breastfeeding to take place as soon as possible.