Date….

In attention to:

Dr. (Gynecologist Name)

Dr. (Peditrician Name)

HOSPITAL (Hospital Name)

Present:

Personal Information:

Name of patient:

Cel Number:

Blood type:

Estimated due date:

I thank you for your attention and I hope that the following requests can be taken into account:

 I wish to be informed about the evolution of the birth and to be involved in the
decisicions about it.
 Throughout the birth process, I would like to be accompanied by (Name of father.
 I want privacy to be favored in the process and that no more people apper than
necessary.
 I want to be allowed to spend as much time as possible at home in labor and enter the
hospital with advanced dilatation of the active pase.

Procedural preferences:

I prefer:

 Do not give me an enema.

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  They allow me to adopt the position that I want and allow me to have a better evolution
in my labor (lying down, sitting, free movement in the room labor room and hospital).
 I want to drink water o fluids and eat food, if labor is progressing well.
 Spontaneous urination is favored for me, without catheter.
 The number of vaginal examinations are the mínimum necessary to assess the evolution
of labor.
 I wish that oxytocin or ther drugs to accelerate or stimulate my labor not be
administered to me, unless there is a special condition, for which I request that you be
informed and authorized by me.
 I would not like my membranes to rupture.
 In the event that I need any medication, I want to be informed and consulted
beforehand.
 In the presence or participation of other people is necessary, the consent of the mother
and/or partner will be requested.
 I would like to be able to use my birthing ball.
 I would like to be able to listen to my playlist.
 I would like to have aromatherapy.
 Wear my own clothes inside the hospital.
 Do not remove pub hair. .

Venous route:

 I do not want an IV to be placed unless it is necessary.

Fetal Control:

 I want my baby´s heartbeat to be detected by doppler.

Relief from pain:

 I don´t want an epidural. I prefer that the apply alternatives for pain relief (Shower,
bath, breathing, etc.) however, I do not rule out their use with prior consent.
 I would like to decide on the type of pain relief technique at the time of delivery.

Birth Preferences:

I would like to give birh in a calm and intimate environment (dim light, silence,
comfortable temperatura and only the necessary personnel of

the hospital, my husband, to facilitate the physiological process of childbirth.

 I want immersion in the tub with hot water.

 I want my husband to be able to get in the tub with me.
 If the birth takes place in the tub, I want my husband to be the one to receive my baby
with the help of the gynecologist.

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  Use the most comfortable position to give birth to my baby.
 Not to have an episiotomy if it is not absolutely necessary.
 In case of a necessary c-section, I ask you to lower the surgical sheets so that I can see
the moment my baby is born.
 In the case of a c-section, I ask that you not give me general anesthesia after the birth,
since I want to be able to have my baby at the breast while the surgery is finished.
 Please place my baby skin to skin inmediately after he is born.
 I want to cut the umbilical cord, when all the bood from the baby placenta has passed
and it is my husband and who do it.
 I want my husband to be with me in the c-section.
 I want the placenta delivered to me.


Attention to my baby:

 Don´t aspirate my baby´s mucus if the onset of breathing is spontaneous, and do not
insert rectal probes o gastric lavages if it is not necessary.
 Promote the initiation of breastfeeding immediately and spontaneous, for as long as
necessary.
 We don´t want the baby to be in the nursery.
 We want his first bath to be done at home, please don´t bathe him in the hospital.
 Exclusive breastfeeding.
 Do not apply vitamin K.

Thank You

(Name of Pacient)

Here's the corrected version of the text:

Date: [Insert Date]

In attention to:

Dr. [Gynecologist Name]

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Dr. [Pediatrician Name]

[Hospital Name]

Present:

Personal Information:

Name of patient:

Cell Number:

Blood type:

Estimated due date:

I thank you for your attention and I hope that the following requests can be taken into account:

- I wish to be informed about the progress of the birth and to be involved in the decisions about
it.

- Throughout the birth process, I would like to be accompanied by [Name of father].

- I want privacy to be respected during the process, and only necessary personnel should be
present.

- I want to spend as much time as possible at home during labor and enter the hospital with
advanced dilation of the active phase.

Procedural preferences:

I prefer:

- Not to receive an enema.

- To be allowed to adopt the position that I want and have freedom of movement in the labor
room.

- To be allowed to drink water or fluids and eat food if labor is progressing well.

- Spontaneous urination without the use of a catheter.

Página 4 de 6
- The minimum number of vaginal examinations necessary to assess the progress of labor.

- Oxytocin or other drugs to accelerate or stimulate labor should not be administered to me

unless there is a special condition. In such cases, I request to be informed and give my
authorization.

- Not to have my membranes ruptured.

- To be informed and consulted beforehand if any medication is needed.

- In the presence or participation of other people, consent from the mother and/or partner will be
requested.

- To be able to use my birthing ball.

- To be able to listen to my playlist.

- To have aromatherapy.

- To wear my own clothes inside the hospital.

- Not to have pubic hair removed.

Venous route:

- I do not want an IV unless it is necessary.

Fetal Control:

- I want my baby's heartbeat to be detected by a doppler.

Relief from pain:

- I don't want an epidural. I prefer alternative pain relief methods such as a shower, bath,
breathing techniques, etc. However, I do not rule out the use of an epidural with prior consent.

- I would like to decide on the type of pain relief technique at the time of delivery.

Birth Preferences:

I would like to give birth in a calm and intimate environment with dim light, silence, and a
comfortable temperature, with only necessary hospital personnel and my husband present to
facilitate the physiological process of childbirth.

Página 5 de 6
- I want immersion in a tub with hot water.

- I want my husband to be able to join me in the tub.

- If the birth takes place in the tub, I want my husband to be the one to receive the baby with the
help of the gynecologist.

- Use the most comfortable position for giving birth.

- Not to have an episiotomy unless absolutely necessary.

- In case of a necessary c-section, I ask that the surgical sheets be lowered so that I can see the
moment my baby is born.

- After the c-section, I ask not to be given general anesthesia since I want to be able to have my
baby at the breast while the surgery is finished.

- Please place my baby skin to skin immediately after birth.

- I want to cut the umbilical cord when all the blood from the baby's placenta has passed, and I
want my husband to do it.

- I want my husband to be with me during the c-section.

- I want the placenta to be delivered to me.

Attention to my baby:

- Do not aspirate my baby's mucus if breathing starts spontaneously, and do not perform rectal
probes or gastric lavages unless necessary.

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