Free Birth Preferences Conversation Sample

This free sample is a starting point for organizing questions and preferences to discuss with your care team during labor and delivery. It is a conversation aid, not a formal legal agreement.

The sample reflects the author's understanding of informed consent and refusal as described in professional obstetric guidance. Informed consent is an ongoing conversation, and options or requirements can vary by situation. Consider adapting the wording with your care team and, if needed, a qualified attorney.

Sample preference statement

The patient asks to discuss proposed interventions, including their purpose, risks, benefits, and alternatives where appropriate. She requests that the following procedures not be performed without her informed consent:

• Cesarean section
• Labor induction or augmentation (for example, Pitocin)
• Operative vaginal delivery
• Vaginal exams
• Episiotomy

The patient asks that her preferences and decisions be discussed and documented throughout care. This sample does not provide legal or medical advice and cannot guarantee a particular care decision or outcome. Laws, clinical circumstances, and facility policies vary.