Birth Plan

1. Name:
2. Partner's Name:
3. Doula/labor Assistant:
4. Due Date:

1. Allergies:
2. Blood Type:
3. Rh Factor:

1. Health Care Provider Name:
2. Hospital/Birthing Center where you plan to deliver:

1. not to be induced
2. to be induced

1. Stripping or breaking membranes
2. Prostaglandin gel
3. Breast Stimulation
4. Castor oil and/or enema
5. Herbs
6. Walking
7. Sexual intercourse
8. Pitocin

1. I would like the following to be present during labor:
2. I would like the following to be present during actual birth:

1. I would like to bring music.
2. I would prefer dim lighting
3. would like to wear my own clothes.
4. I would prefer to stay in one room during labor, birth, and post delivery if available
5. I would like to be able to film baby's birth.
6. I would prefer no students to be present.
7. I would like to be able to walk around, mobility is important to me.
8. I would prefer a warm bath over walking. Please let me try that if I do not feel up to walking.

1. Birthing bed
2. Birthing ball
3. Birthing stool
4. Beanbag
5. Birthing pool or tub
6. Shower

1. to be given an enema
2. not to be given an enema
3. I would like to wear contact lenses if possible.
4. I would prefer to be able to eat and drink during labor.
5. I would prefer no IV unless absolutely necessary.
6. If I need an IV, I would like to use a heparin or saline lock

1. I would prefer no monitoring to be done if there are no signs of distress.
2. I would prefer external monitoring if monitoring is necessary.
3. I am comfortable using an internal monitor.

1. I would prefer to try laboring without pain medication. I will ask if I would like something for pain. Please do not ask me.
2. I would like to try narcotic medications before being offered an epidural.
3. I would like an epidural.
4. I would like a walking epidural.

1. I do not want to be separated from my partner during labor or birth.
2. I would like the option of returning home if my labor is not progressing.
3. I would like no time limits on laboring and prefer labor not to be augmented unless medically necessary.
4. I would prefer my water not be broken during labor.
5. I would prefer vaginal exams kept to a minimum.
6. I would like encouragement throughout labor.

1. I'd prefer not to have an episiotomy.
2. I'd prefer to have an episiotomy.

1. I'd like a mirror present to view birth.
2. I'd like to be able to touch baby's head when it crowns.
3. I'd like coach and/or nurse to support my legs when I push.
4. I'd like to be able to try any position comfortable during pushing.
5. I would like to wait to push until I feel the urge even if I am fully dilated.
6. I would like no time limits on pushing.
7. I would like counting to help me push.

1. I'd like my partner to catch the baby.
2. I'd like to have baby placed on my chest immediately after birth.
3. I'd like to cut the cord myself.
4. I'd like to have my partner cut the cord.
5. I'd like to wait on cutting the umbilical cord until it stops pulsating.
6. My partner does not wish to cut the cord. Please do not ask.
7. I'd like to have baby's first bath and assessment to be done in my presence.
8. I would like to see my placenta after birth.
9. I do not wish to see my placenta after birth. Please do not show it to me.
10. I would like to bank baby's umbilical cord blood.
11. I would like to donate my baby's umbilical cord blood.
12. I would like baby to room in with me.
13. I would like baby to stay in nursery at night so I can rest.
14. I would like my partner to stay in the room with me.
15. I'd like to be discharged as soon as possible.
16. I'd like to stay as long as possible.

1. I would like to avoid a c-section if possible.
2. If c-section is necessary, I would like my partner present.
3. I would like to touch the baby after birth.
4. I would like my partner to hold the baby after birth.
5. I would like the screen lowered so I can view the birth.
6. I would like to film c-section.
7. I would like to breastfeed my baby as soon as possible.

Breastfeeding

1. Bottlefeed
2. Breastfeed
3. Breastfeed and bottlefeed

1. I do not want my baby to have a pacifier.
2. I would like my baby to have a pacifier. I am aware of the risks for niple confusion.
3. I do not want my baby given any formula or water.
4. I do not want my baby to have a bottle. I would prefer a cup feeding or finger feeding if supplements are necessary.
5. I would like to see a lactation consultant.
6. I would like any gift bags or diaper bags given to have formula removed.

1. I do not want to have my baby circumcised.
2. I would like my baby circumsised in the hospital.
3. I would like to have my baby's circumcision done after discharge.
4. I would like anesthesia to be used during circumcision.
5. I would like to be present during circumcision.