My Birth Plan

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Basic information:

• Name: ______________
• My support person's name: ______________
• Hospital/birthing center: ______________
• Due date/induction date: ______________
• Practitioner's name: ______________

Before labor:

• My health factors include the following:

□ Group B Strep

□ Rh Negative

□ Hypertension

□ Gestational Diabetes

□ Other:

• My planned delivery date is: ______________
• My birth team includes:

□ It is okay to discuss my health information in front of my partner

□ Only disclose current plan of care of the labor and delivery process and exam findings in front of my partner

□ Please don’t discuss my health information in front of any of the following:

• Partner
• Family
• Support person

• The Gender of my baby is:

□ A Surprise

□ Is a boy or girl (Circle one), Name:

During length labor:

If medically possible, I would like to (check all that apply):

□ Drink water and eat ice chips during labor if my practitioner allows it

□ Wear my own clothes

□ Play music, dim lighting, use incense, scented candles

□ Allow my partner to take pictures and video within the limits of organizational policy

□ Would prefer not to have students

During first stage of labor: I’d prefer the following:

□ Be out of bed (walking around or sitting up)

□ Be allowed to sleep

□ Shower

□ Bathtub

□ Labor with an exercise ball, in-room shower or birthing tub

During first stage of labor: I’d prefer to avoid the following:

□ Shaving of the pubic area

□ A urinary catheter

□ An IV, unless I’m dehydrated

• An IV lock is okay in case an emergency arises
• An IV is not preferred until needed

□ Enemas

Fetal Monitoring Methods I prefer if medically indicated:

□ Intermittent

□ Continuous

□ External

□ Internal

Labor Augmentation I preferred only if:

□ My baby is in distress

□ My labor is not progressing after 6-8 hours

Labor Augmentation I prefer:

□ Natural methods of inducing contractions using nipple stimulation

□ Stripping of membranes

□ Prostaglandins

• Foley Bulb
• Cervidil
• Cytotec

□ Pitocin

□ Rupture of membranes

Pain Management I prefer:

□ Don’t discuss pain medication or Epidural options with me because I want to deliver naturally, I am only willing to do the following:

• Coached Breathing techniques
• Cold therapy
• Distraction
• Hot therapy
• Support massage and counter pressure

□ Discuss pain management options with me only if I seem uncomfortable

□ Discuss the following pain management options with me when ONLY I request information

• Medication options
• Standard epidural

During second stage of labor: I’d prefer the following:

□ Use specific birthing positions (Check all that you prefer)

• Squat
• Semi-recline
• Lie on my side
• Be on my hands and knees
• Stand
• Lean on my partner
• Use people for leg support
• Use foot pedals for support
• Use a birth bar for support
• Use a birthing stool

□ Minimal vaginal exams

□ Intermittent or doppler fetal monitoring

□ Natural tearing only

□ Other:______________

I would like an Episiotomy:

□ Used only after perineal massage, warm compresses and positioning

□ Rather than risk a tear

□ Not performed, even if it means risking a tear

□ Performed only as a last resort

□ Performed as my doctor deems necessary

□ Performed with local anesthesia

As my baby is delivering, I would like to:

□ Avoid forceps usage

□ Avoid vacuum extraction

□ Push spontaneously

□ Push as directed

□ Push without time limits, as long as the baby and I are not at risk

□ Use a mirror to see the baby crown

□ Touch the head as it crowns

□ Let the epidural wear off while pushing

□ Have a full dose of epidural

□ Use whatever methods my doctor deems necessary

□ Have support person/ husband/ partner help catch the baby

□ Allow me to assist catching my baby

After I deliver my baby:

□ My partner to cut the umbilical cord

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

□ To deliver the placenta spontaneously and without assistance

□ To see the placenta before it is discarded

□ I want to keep my placenta

• I will bring the proper cooler to store it in and have someone available to pick it up before I am transferred to Post Partum

□ Not to be given Pitocin/oxytocin unless I have risk of hemorrhaging

In case of a C-section:

If medically possible, I would prefer (Check all that apply, or make a note next to any you'd like to avoid):

□ Ensure all options have been exhausted

□ To be awake

□ Clear drapes be set up so I can watch as my baby emerges

□ Arms to be left free so I can hold the baby

□ Skin to skin in the delivery room if my baby is okay

□ To breastfeed as soon as possible

After I deliver my baby:

□ Immediately after delivery for skin to skin

□ After suctioning

□ After weighing

□ After being wiped clean and swaddled

□ Before eye drops/ointment are given

Newborn care:

If medically possible, I would like to (Check all that apply, or make a note next to any you'd like to avoid):

□ Breastfeed immediately

• Before eye ointment is given
• Later
• Never
• Have a lactation consultant help me breastfeed
• Give my baby breast milk only

□ Give my baby formula

□ Offer my baby a pacifier

□ Have circumcision performed if baby is a boy

□ I’d like my baby’s first bath given

• In my presence
• In my partner’s presence
• By me
• By my partner

Newborn Medications:

□ Please don’t give my baby

• Vitamin K
• Antibiotic eye treatment
• Hepatitis B vaccine (Choose One)
  • I will get this done at the pediatrician
  • I do not want my baby vaccinated

□ Please give my baby

• Give my baby vitamin K
• Give my baby antibiotic eye treatment
• Give my baby hepatitis B vaccine

Newborn Screenings and Exams:

□ Done in my presence

□ Given only after we’ve bonded

□ Given in my partner’s presence

□ To include a heel stick for screening tests beyond the PKU

□ To include a hearing screening test

□ To include a hepatitis B vaccine