Your Birth Plan is important to you in the transition to motherhood. Having everyone in your support circle informed of your decisions about the way you want to birth can allow you to focus inward on what you and your baby need while birthing.

This is a comprehensive birth plan that lays out most of the information about how your birth can go. It can be a lot of information to digest, so If you have any questions about any of your choices, I’d be happy to provide more information or meet with you for a free consultation.

This is your birth and you have the final say as a birthing mother, wherever you birth. I hope that makes you feel empowered and wanting to be informed. A Birth Plan is great to discuss with your OB or Midwife and to provide a copy for each person on your birthing support team. Use this as you’d like!

My Birth Plan

 

My Name: ________________________________________       Partner’s Name: _________________________________________________

Due Date/Induction Date: ____________________________     OB/Midwife: ___________________________________________________

Hospital/Desired Birthing Location: _____________________   Pediatrician: ____________________________________________________

Baby’s Name(optional): ______________________________ Doula(optional): _________________________________________________

 

Please note that I:

____ Have Group B strep                   Take the following medications: _________________________________________________________________

____ Am Rh incompatible with baby  Have the following medication allergies: __________________________________________________________

____ Have gestational diabetes         Other: _____________________________________________________________________________________

____ Am positive for herpes              _____ None of the Above

 

My Delivery is Planned As:                 I have completed the following:

____Vaginal                                        ____ Hospital admission forms, if applicable

____ C-section (Belly Birth)                 ____ Insurance Forms

____ Water Birth                                 ____ Cord Blood/Placenta banking/encapsulation instructions

____ VBAC                                          ____ Other: ___________________________________________

 

Labor Preferences

In the delivery room, I want:                                      In the delivery room, I want:

____ Dim lighting                                                       ____ Partner: ______________________________

____ Birthing ball                                                       ____ Parents: ______________________________

____ Music that I will provide                                    ____ Children: _____________________________

____ Minimal sound                                                   ____ Doula: _______________________________

____ Blankets and/or photos from home                   ____ Friend: _______________________________

____ Aromatherapy scents that I will provide           ____ Other: _______________________________

____ One of my support people taking photos

____ As few vaginal exams as possible

____ Hospital staff limited to my own doctors and nurses (no students, residents or interns present)

____ To wear my own clothes

____ To wear my contact lenses the entire time

____ My partner to be present the entire time

____ To stay hydrated with clear liquids and ice chips

____ To eat and drink as approved by my doctor

____ Other: ___________________________________________________________________________________________________________________

 

Options to Help with Contractions

____ Walking around                                                  ____ Nipple stimulation

____ My doctor or midwife can break my water       ____ Other: _________________________________________________________________________

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Options to Help Prepare My Cervix

____ Dinoprostone cervical ripening vaginal insert, FDA approved

____ Dinoprostone cervical ripening gel, FDA approved

____ Pill (Cytotec/misoprostol), not FDA approved for cervical ripening

____ Balloon catheter, some are FDA approved

____ Other: ___________________________________________________________________________________________________________________

 

For Labor Comfort Measures I’d like to use:

____ Acupressure                                           ____ Massage

____ Acupuncture                                          ____ Meditation

____ Breathing techniques                             ____ Reflexology

____ Cold therapy                                          ____ Bath tub

____ Demerol                                                 ____ Shower

____ Distraction                                             ____ Standard epidural

____ Hot therapy                                            ____ TENS

____ Hypnobirthing techniques                     ____ Walking epidural

____ IV medications                                       ____ Please do not offer me pain medicine. I will request it

____ Other: ___________________________________________________________________________________________________________________

 

During labor & delivery I would like to:

____ Squat                                                      ____ Use people for leg support

____ Semi-recline                                           ____ Use foot pedals for support

____ Lie on my side                                        ____ Use birth bar for support

____ Be on my hands and knees                    ____ Use a birthing stool

____ Stand                                                     ____ Be in a birthing tub

____ Lean on my partner                                ____ Be in the shower

 

As the baby is delivered, I would like to:

____ Push spontaneously                                ____ Avoid forceps usage

____ Push as directed                                    ____ Avoid vacuum extraction

____ Use a mirror to see the baby crown      ____ Use whatever methods my doctor deems necessary

____ Touch the head as it crowns                  ____ Help catch the baby

____ Let the epidural wear off while pushing ____ Let my partner catch the baby

____ Have a full dose of epidural                   ____ Let my partner suction the baby

____ Push without time limits, as long as the baby & I are not at risk

 

In Case of Interventions such as Vacuum, Forceps or Episiotomy, May I Request:

____ If I need any of these procedures, please discuss with me beforehand

____ I would prefer not to have an episiotomy unless medically necessary

____ I would prefer not to have forceps used

____ I would prefer not to have vacuum used

____ I would like an episiotomy rather than risk a tear

____ I would not like an episiotomy even if it means a tear

____ If necessary, I would like an episiotomy performed with local anesthesia

 

In Case of C-section (Belly Birth) and it’s not an emergency, I would like:

____ A second opinion

____ To stay conscious

____ My hands left free so I can hold/touch the baby

____ An epidural for anesthesia

____ My partner to hold the baby as soon as possible

____ To breastfeed in the recovery room

____ If possible, I would like some alone time with my partner/other prior to the procedure

____ I’d like to have a support person be present for the procedure

____ I’d like a sheer screen to watch, if possible

____ I’d like to have music playing

____ I’d like to have the procedure explained as it happens

____ If possible, I’d like to have immediate skin to skin contact with my baby

____ Other: ___________________________________________________________________

 

Immediately After Delivery, I Would Like:

____ My partner to cut the umbilical cord

____ The umbilical cord to be cut only after it stops pulsating

____ To bank the cord blood

____ To donate the cord blood

____ To deliver the placenta spontaneously and without assistance

____ To see the placenta before it is discarded

____ To take the placenta home

____ Not to be given Pitocin/oxytocin

 

I Would Like to Hold Baby:                                                     I Would Like to Breastfeed:

____ Immediately after delivery                                            ____ As soon as possible after delivery

____ After suctioning                                                             ____ Before eye drops/ointment are given

____ After weighing                                                              ____ Later

____ After being wiped clean and swaddled                        ____ Never

____ Before eye drops/ointment is given                              ____ I want to see a lactation consultant

 

I Would Like Hepatitis B Vaccination for my baby

____ Yes                     ____ No

 

If Baby is a Boy, a Circumcision Should:

____ Be performed prior to leaving the hospital

____ Be performed with anesthesia

____ Be performed in the presence of me and/or my partner

____ Not be performed prior to leaving the hospital

____ Not be performed

 

I Would Like My Family Members; ___________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

____ To join me and baby immediately after delivery           ____ To join me and baby in room later

____ Only to see baby in nursery                                          ____ To have unlimited visiting after birth

 

I would like baby’s medical exam & procedures:

____ Given in my presence                                                    ____ Given only after we’ve bonded

____ Given in my partner’s presence                                     ____ To include a hearing screening test

____ To include a hepatitis B vaccine ____ to include a heel stick for screening tests beyond the PKU

 

Please Don’t Give Baby:                                               I’d Like Baby’s First Bath Given:

____ Vitamin K                                                           ____ In my presence

____ Antibiotic eye treatment                                   ____ In my partner’s presence

____ Sugar water                                                       ____ By me

____ Formula                                                             ____ By my partner

____ A pacifier

 

I’d like Baby to Stay in My Room:                                I’d Like My Partner:

____ All the time                                                         ____ To have unlimited visiting

____ During the day                                                   ____ To sleep in my room

____ Only when I’m awake

____ Only for feeding

____ Only when I request

 

As Needed Post Delivery, Please Give Me:                  After Birth, I’d like to stay in the Hospital:    

____ Extra-strength acetaminophen                         ____ As long as possible

____ Percoset                                                              ____ As briefly as possible

____ Stool softener

____ Laxative

 

If My Baby is Not Well, I’d like:

____ My partner and I to accompany it to the NICU or another facility

____ To breastfeed or provide pumped breastmilk

____ To hold him or her whenever possible