Answer a few quick questions to create a simple, one-page birth preferences sheet to share with your care team.

Basic Info

Let’s start with the basics.

Full Name Partner Name Second Support Person Due Date Provider Group Doula Name + Phone

Baby

Would you like this included?

Boy Girl Surprise

Labor

Choose what would help during labor.

Freedom to move and change positions Position change support Use of shower or tub if available Eat and drink as allowed

Monitoring

Choose any monitoring preferences.

Intermittent monitoring if possible Continuous monitoring if needed

Pain Management

Select what feels true for you right now.

Hoping to go unmedicated Please do not offer an epidural unless I ask Open to an epidural Planning to get an epidural Open to IV pain medication TENS or other non-medicated options Want support deciding in the moment

Interventions

Choose what you’d like clearly communicated.

Avoid breaking water (AROM) unless medically necessary Avoid Pitocin during labor unless medically necessary Avoid Pitocin after delivery unless medically necessary No episiotomy unless discussed and consent is given Discuss before non-urgent interventions Comfortable following provider recommendations

Pushing

Choose any preferences for pushing.

Follow my body’s natural urges Open to using a squat bar if available Open to trying different pushing positions

After Birth

Choose what matters most right after birth.

Immediate skin-to-skin Partner/support person to cut cord Partner/support person to announce baby’s sex Delayed cord clamping for minutes

Newborn Care

Choose newborn care preferences.

Vitamin K injection Erythromycin eye ointment Hepatitis B vaccine Delay baby’s first bath

Feeding

Choose what you’d like your care team to know.

Planning to breastfeed Planning to bottle feed Open / undecided Offer expressed breastmilk before formula if needed No formula without parental consent Open to formula if needed Using hospital formula Using formula brought from home Lactation consultant support requested

Final Notes

Anything else you want your care team to know?

Your One-Page Birth Preferences Sheet

Review your selections. Use Back to make changes, then print or save as a PDF.

Let’s build your Birth Preferences