CMOMB
a Fellowship of Christian Moms
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Your name:
Your Spouse/friend’s name:
Due Date:
ALLERGIES TO MEDICATIONS:
Name of doctor/midwife:
Name of midwife/doula or support person (other than spouse):
PREPARATION: Do you want…
An enema? Yes No
Shave/prep? Yes No
Private room? Yes No
Hospital gown? Yes No
Heparin/Saline Lock (Most hospitals require this as access to a vein should an emergency occur) Yes No
Freedom to bring/play own music? Yes No
Your own clothing? Yes No
Intravenous drip in labor? Yes No
Consent to be a teaching patient (students and staff may be present at any time)? Yes No
LABOR: Do you want…
Food/fluids on request throughout labor? Yes No
Not to be offered pain medications during labor/delivery? Yes No
Not to be offered pain medications during labor/delivery, but would like to keep the option open if I request it? Yes No
Pain medications as soon as possible? Yes No
Freedom to shower or labor in a tub? Yes No
External electronic fetal monitoring for test strip only? Yes No
Internal electronic monitoring (this requires rupture of membranes and attachment of electrode to baby’s scalp in utero.)? Yes No
Monitoring baby’s heart tones by hand doppler? Yes No
One-to-one nursing support and care during labor? Yes No
Freedom to choose positions and activity in labor (walking, sitting, squatting, lying on side, etc.)? Yes No
Examination for specific medical indication only? Yes No
Lying in bed during labor? Yes No
Full information on risks and benefits of each suggested medical procedure? Yes No
“Routine” artificial rupture of membranes? Yes No
Artificial hormone (Pictocin typically) to boost contractions or induce labor? Yes No
Analgesia or anesthesia for pain in labor? Yes No
Spouse/chosen person present from entry to hospital through labor? Yes No
Spouse/chosen person present during any medical procedure? Yes No
Admission papers complete in mother’s room? Yes No
BIRTH: Do you want…
Episiotomy? Yes No
Freedom of position during birth? Yes No
Minimal number of staff in room? Yes No
Freedom to touch baby during delivery? Yes No
Father assisting with actual delivery by hand? Yes No
Hot compresses and massage to help the perineum stretch? Yes No
Father cutting the cord? Yes No
Freedom to take photographs/videotape throughout? Yes No
Midwife/doula attending? Yes No
Female, rather than male, physician? Yes No
Delivery room warmed for birth above 70°? Yes No
Dimmed lights for actual birth? Yes No
No mask worn by father during birth (to enhance contact with baby)? Yes No
Baby allowed to take first breaths unassisted (no immediate suctioning, etc.)? Yes No
Late cord clamping (after pulsating stops)? Yes No
Skin-to-skin contact with baby immediately after birth for mother and father? Yes No
Baby cleaned before presenting to mother? Yes No
“Routine” artificial hormone injection after delivery to contract uterus and expel placenta? Yes No
Baby on breast to stimulate the uterus contractions and expel placenta? Yes No
Electronic warmer for baby? Yes No
Erythromycin delayed at least one hour? Yes No
Mirror placed for birth? Yes No
Freedom to touch baby during delivery? Yes No
Vernix (creamy secretion on skin at birth) left on? Yes No
Siblings present for birth? Yes No
Vitamin K shot to baby? Yes No
Measuring, weighing to be done in room? Yes No
Father to accompany baby to be weighed and measured? Yes No
RECOVERY: Do you want…
Baby remains in nursery, except for feedings? Yes No
Baby remains with mother at all times (nights included)? Yes No
Visitors of choice in mother’s room at any time of day? Yes No
Breast feeding on demand from birth? Yes No
Bottle feeding only? Yes No
Both a combination of breast and bottle feeding are fine? Yes No
Sugar water between feedings? Yes No
A note to be placed on my door asking for visitors to knock first? Yes No
Freedom of movement for mother after birth (shower, etc.)? Yes No
Circumcision? Yes No
Both a combination of breast and bottle feeding are fine? Yes No
Circumcision delayed until 8th day? Yes No
Early discharge from hospital as soon as baby and mother are stable (hospital personnel availble for support by phone)? Yes No