Appendix: Birth Preference Sheets
The following pages are copies of the worksheets that your HypnoBirthing practitioner will provide for your use in designing your birth preferences. It is a good idea to complete the Birth Preference Sheets prior to touring the facility you will use for your birthing. You may wish to discuss some of the items with the person conducting your tour.
This plan has been developed for use throughout the United States and in several foreign countries. For that reason, you will find items on the plan that may not apply to you or the facility at which you will birth. Several of the items that are listed have been adopted by most hospitals and staff long ago. However, many of the requests that are routinely honored in some geographic areas are as yet unheard-of in other areas of this country and outside of the United States. You may skip these items, mark them N/A, or extract only those that apply to your own preferences.
Letter to Health-Care Providers:
Dear Health-Care Provider:
My birthing companion and I have chosen you, our medical advisor, and you, our birthing facility staff, as the people we want to attend us when our baby is born. We have chosen the HypnoBirthing method of quiet, relaxed, natural birth. From everything we have heard from others, we truly believe that you will do your utmost to help us attain our wish for a joyous, memorable and most satisfying natural birth.
The information that follows is a copy of our birth preferences. My birthing companion and I have given careful consideration to each specific request in the plan, and we feel that it represents our wishes at this time. We realize that as labor ensues, we may choose to change our thinking and wish to feel free to do so. We understand that these choices presume a normal pregnancy and birth. Should a situation arise that constitutes a medical emergency, please know that you will have our complete cooperation after we have had an opportunity for an explanation of the medical need and have had sufficient time to discuss the decision between ourselves. We wish to have clear explanations of all suggested procedures, of the progress of labor as it is assessed, and of any possible special circumstances if they occur. In the absence of special circumstances, we ask that the following requests be honored.
Please attach this to my prenatal record and make it available to all physicians/staff who may be attending the birth should you not be attending us.
I will provide copies for the:
hospital Labor and Birthing Unit 
birthing clinic 
my midwife
Your support and understanding are very much appreciated.
Signed: ________________________________
Birth Preference Sheets
Pre-Admission Requests
We request:
To complete all required paperwork during a pre-admission visit to eliminate interruption during relaxation for labor.
To consider artificial initiation of labor only if labor is unusually delayed and there is medical urgency.
To delay artificial induction of labor for a reasonable period after the release of membranes if mother and baby show no signs of infection.
To remain at home as long as possible before going to the hospital.
OTHER REQUESTS: _____________________________________
________________________________________________________
For Hospital Admission
We request:
The patience and understanding of caregivers to support our wish to refrain from having any practice or procedures that, in the absence of medical urgency, could unnecessarily stand in the way of our having the most natural birth possible.
The opportunity to discuss our birth preferences with our assigned nurse.
To return home until labor progresses if less than 4 centimeters opened and if there are no situations that warrant admission.
To be assigned a nurse who is partial to natural birthing.
To choose wheelchair assistance or to walk to my room.
To self-hydrate and decline routine IV prep upon admission.
Natural means of inducement, moving to minimum doses of artificial induction only if medically urgent.
That artificial induction drugs be removed once uterus is naturally thinning and opening.
To have a private labor and birthing room, subdued lighting, music and quiet tones.
To have only intermittent monitoring (EFM) of FHR after the mandatory twenty-minute strip at admission.
To have the following persons present during my birthing:
husband 
other birthing companion
relative 
labor support person
To have pictures and/or video of this important time in our lives.
To have telephone calls relayed to our room.
To have no telephone calls relayed—only messages.
To respectfully decline to participate in the taking of pain scale information.
OTHER REQUESTS: _____________________________________
________________________________________________________
During First-Stage Labor
We request:
The patience and understanding of care providers to support our wish to refrain from any procedures or practices that in the absence of medical urgency could unnecessarily stand in the way of our having the most natural birth possible.
To have only necessary hospital staff or cheerful observers, please.
That staff refrain from references to “pain, hurt, etc.” and any offer of medication or labor-enhancing procedures unless requested.
To be free of blood-pressure cuff between readings.
Manual intermittent monitoring after pattern is established.
Internal monitoring only in the event of medical urgency.
Nutritional snacking if labor is prolonged.
Freedom to walk and move or not walk or move during labor.
To change positions and assume labor positions of choice.
Minimal number of vaginal exams—with permission—to avoid premature rupture of membranes.
That labor be allowed to take its natural course without references to “moving things along” or “augmenting labor.”
To use natural oxytocin stimulation—nipple or clitoral stimulation—in the event of a slow or resting labor, and to be accorded the privacy to do so.
To be fully apprised and consulted before the introduction of any medical procedure—augmentation, amniotomy, membrane stripping.
To enjoy labor tub or shower.
OTHER REQUESTS: _____________________________________
________________________________________________________
During Birthing
We request:
The patience and understanding of care providers to support our wish to refrain from any procedures or practice that, in the absence of medical urgency, could unnecessarily stand in the way of our having the most natural birth possible.
To remain in the tub for waterbirthing if available (arranged beforehand).
That natural expulsive pulsations of the body be allowed to facilitate the gentle descent of the baby, with mother-directed Birth Breathing to crowning. Birth companion will offer prompts. No coaching.
Use of HypnoBirthing breathing techniques—not other methods.
To assume a birthing position of choice that will least likely require an episiotomy.
Use of warm-oil compresses to avoid episiotomy. No perinatal massage to perineum.
Episiotomy only if necessary and only after discussion.
Use of topical anesthetic for episiotomy.
Complete birthing before suctioning baby’s nose and throat.
Videotaping of birth.
To have our other children present 
during 
shortly after birth.
OTHER REQUESTS: _____________________________________
________________________________________________________
Following Birthing
We request:
That father/birth companion announce sex of baby to mother if sex is unknown.
That birth companion or mom receive baby if at all possible.
Immediate skin-to-skin contact, with baby placed on mom’s stomach or lower chest. No wrapping of baby. Father/companion joins in this bonding by placing hand on baby’s back under warming blanket.
Cord to be clamped and cut only after pulsation has ceased.
That father/birth companion will cut cord after it stops pulsating.
That father/companion/labor support be allowed to remain with mom in the operating and recovery room in the event of a C-section.
That father will hold the baby after C-section birth and bring baby to mom for viewing and eye contact. In absence of urgency, father continues to hold baby for bonding.
A wait for natural placenta delivery.
Baby brought to breast to assist placenta birth.
Gentle uterine massage every fifteen minutes to assist placenta birth.
Natural nipple stimulation to assist in placenta expulsion.
No cord traction, manual removal or use of Pitocin for removal of placenta unless necessary.
OTHER REQUESTS: _____________________________________
________________________________________________________
For Baby
We request:
To have bright lights temporarily removed at moment of birth and until baby is moved to mother’s chest.
Allow vernix to be absorbed into baby’s skin; delay “cleaning or rubbing.” Use of a soft cloth, not terry, when rubbing is appropriate.
Baby to remain with mother and birth companion
1/2 hr. o 1 hr. o 2 hrs.
Delay use of ointment in baby’s eyes to allow optimal sight for bonding.
Oral Vitamin K to be used rather than an injection if available.
That a male baby be o circumcised o not circumcised.
That father and baby stay with mother throughout the hospital stay.
To have footprints made in the baby’s birth book.
Breastfeeding several times during the first few hours of baby’s life.
Breastfeeding only. No bottles, formula, pacifier or artificial nipples.
We thank you in advance for your support and kind attention to our choices. We know you join us in looking forward to a beautiful birth and celebration of this new life.