Birth Plan Worksheet
ATTENDANTS AND AMENITIES
I’d like the following people to be present during labor and/or birth:
Partner:
Friend/s:
Relative/s:
Doula:
Children:
I'd also like:
To bring music
To dim the lights
To wear my own clothes during labor and delivery
To take pictures and/or video during labor and delivery
LABOR
I’d like the option of returning home if I’m not in active labor.

Once I’m admitted, I’d like:
My partner to be allowed to stay with me at all times
Only my practitioner, nurse, and guests present (i.e., no residents, medical students, or other hospital personnel)
To wear my contact lenses, as long as I don’t need a c-section
To eat if I wish to
To stay hydrated by drinking clear fluids instead of having an IV
To have a heparin or saline lock
To walk and move around as I choose
As long as the baby and I are doing fine, I’d like:
To have intermittent rather than continuous electronic fetal monitoring
To be allowed to progress free of stringent time limits
If they’re available, I’d like to try:
A birthing stool
A birthing chair
A squatting bar
A birthing pool/tub
I’d like to bring the following equipment with me:
Birthing stool
Beanbag chair
Birthing pool/tub
Other:
When it’s time to push, I’d like:
Do so instinctively
Be coached on when to push and for how long
I’d like to try the following positions for pushing (and birth):
Semi-reclining
Side-lying position
Squatting
Hands and knees
Whatever feels right at the time
As long as my baby and I are doing fine, I’d like the pushing stage to be allowed to progress free of stringent time limits
PAIN RELIEF
I’d like to try the following pain-management techniques:
Acupressure
Bath/shower
Breathing techniques/distraction
Hot/cold therapy
Self-hypnosis
Massage
Medication
Please don’t offer me pain medication. I’ll request it if I need it.
If I decide I want medicinal pain relief, I’d prefer:
Regional analgesia (an epidural and/or spinal block)
Systemic medication
VAGINAL BIRTH
I’d like:
To view the birth using a mirror
To touch my baby’s head as it crowns
My partner to help "catch" our baby
To risk a tear rather than have an episiotomy
The room to be as quiet as possible
After birth, I’d like:
To breastfeed as soon as possible
To wait until the umbilical cord stops pulsating before it’s clamped and cut
My partner to cut the umbilical cord
No to get routine oxytocin (Pitocin) after I deliver the placenta
To hold my baby right away, putting off any procedures that aren’t urgent
C-SECTION
If I have a c-section, I’d like:
My partner present at all times during the operation
The baby given to my partner as soon as he’s dried (as long as he’s in good health)
To breastfeed my baby in the recovery room
The screen lowered a bit so I can see my baby coming out
POSTPARTUM
After delivery, I'd like:
All newborn procedures to take place in my presence
My partner to stay with the baby at all times if I can’t be there
To stay in a private room
To have a cot provided for my partner
I plan to:
Breast feed exclusively
Combine breast-feeding and formula-feeding
Formula-feed exclusively
The following can be offered to my baby:
Formula
Sugar water
Pacifier
Please don't offer anything to my baby at any point
I'd like my baby fed:
On demand
On a schedule
I'd like:
24-hour rooming-in with my baby
My baby to room-in with me only when I'm awake
My baby brought to me for feedings only
To make my decision later depending on how I'm feeling
If my baby's a boy:
I'd like him circumcised at the hospital.
I'll have him circumcised later.
I don't want him circumcised.
Visitation/Going Home:
I'd like my other child(ren) brought in to see me and meet the new baby as soon as possible after the birth.
I'm interested in checking out of the hospital early.
Template created by: Everyday With Evernote