Trinity Health Birth Wishes
We want to help prepare you for labor and the birth of your baby. This form can help you understand options for a
safe and healthy delivery. It is also important to have discussions about your birth wishes with your provider during
your prenatal visits. We will work together toward a healthy and satisfying birth experience.
Your Name: _____________________________________________________ Birthdate: _____________________________
Your Support Person Name(s): _____________________________________________________________________________
Baby’s Name: ____________________________________________ Baby’s Due Date: ______________________________
Your Pediatrician: ________________________________________________________________________________________
TrinityHealthMichigan.org
THMI W05050-2308 BF
What You Can Expect From Us
•
Early labor at home as long as it is safe to do so
•
An IV is inserted upon admission for any possible
emergencies. Fluids do not need to be infusing until
it is medically necessary.
•
Intermittent fetal monitoring for low-risk pregnancies
•
Wireless monitors to allow freedom of movement
when continuous fetal monitoring is needed.
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Discuss eating and drinking during labor with your
provider. Solid foods are restricted for your safety
in the event of an emergency.
•
Options for pain management may include natural
support, shower, position changes, nitrous oxide,
IV medication and/or epidural.
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Episiotomies are done only when medically
necessary
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Immediate skin-to-skin with baby for vaginal and
cesarean section deliveries, unless your newborn
requires medical care.
•
Delayed cord clamping and newborn bath
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We will explain care, procedures and medications
for you and your baby before they are started
•
Breastfeeding and lactation support from trained
nurses and board certified lactation specialists
What I Would Like
What is important to you during your labor and birth?
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Do you have any cultural or religious practices
that are important to you during your childbirth?
What can we do to help you meet these?
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Do you have any concerns, fears or other information to
share that will help us give you the birth that you want?
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Please select any/all options that you would like for your birth:
Vaginal Birth
I would like to choose the position I push in
(kneeling, side lying, squatting, etc).
I would like a mirror for pushing and/or delivery.
I would like my support person to cut the
umbilical cord.
I have a cord blood collection kit to bank my
baby’s cord blood.
I would like to take the placenta home with me
and have brought a cooler to store it.
Cesarean Birth
I would like to watch my baby deliver, when possible.
I would like my support person to shorten the cord.
Newborn Care
I plan to breastfeed.
No supplementation, please. If my baby needs
formula/supplementation for a medical reason,
I want to be told beforehand.
I plan to formula feed my baby.
If I have a boy, I plan to have him circumcised.
I want to be present and/or participate in
the first bath.
I prefer to hold my baby during procedures
to provide comfort and decrease pain.
I want my baby to receive the hepatitis B vaccine.
I want my baby to receive erythromycin
eye ointment.
I want my baby to receive the vitamin K injection.
I want to discuss the risks and benefits of the
hepatitis B vaccine, erythromycin eye ointment and/
or the vitamin K injection with my health care team.
I have discussed my birth wishes with my provider during prenatal visits and we both understand the plan. I realize that
we may not be able to follow this as written, and changes may happen to have a safe, healthy delivery for myself
and my baby.
My signature: ____________________________________________________ Date: ________________________________
Provider signature: ________________________________________________ Date: ________________________________
Trinity Health Birth Wishes
Room
I would like the lights dimmed during labor.
I want to play music; I will bring my own music device.
I want to bring essential oils / aromatherapy from home.
Labor
I would like to have free movement (walking,
standing, birthing ball, kneeling, etc.) if safe to do so.
I prefer to let labor progress naturally or walk around
before trying Pitocin to speed up labor.
I prefer to wait for the amniotic sac (bag of water)
to break on its own, please discuss artificial rupture
with me first, if the need arises.
I prefer as few cervical exams as possible.
I wish to be surprised by the gender of my baby
until birth. I want ____________________________
(person’s name) to announce the baby’s gender.
I plan to have a doula present to assist me.
My doula’s name is ___________________________.
Coping
I want to have natural childbirth without any pain
medication. Please do not offer me pain relief options
(IV medicine or epidural). I will tell my nurse if I change
my mind and want other options for my pain.
I plan to use nitrous oxide.
I plan to have IV pain medicine.
I plan to have an epidural.
I am unsure whether I want any pain medication,
but will decide when I am in labor. Please discuss
my options with me while I am in labor.