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Birth Plan

When it comes to the birth of your baby, it’s really important to plan beforehand. This could be the most stressful time in your life, so it’s probably best if you consider specific things about the birth before you actually go into labor. A birth plan is a simple, clear statement that your healthcare provider, partner, family, and friends can read and understand, so that everyone knows your preferences for the birth. Of course, if complications arise, your healthcare provider may elect not to follow your birth plan in order to protect your health and safety and that of your baby. Still, it’s a good idea to sit down and make a birth plan so that everyone is on the same page.

Use our sample birth plan to help you get started:

Before Labor Begins:

_ As long as it’s permissible, I’d like to wait at least two weeks after my due date to induce labor

_ As long as my baby and I are healthy, I would like no time restrictions on my delivery

_ I would like to discuss the possibility of induction before labor begins

_ I prefer to go into labor naturally

­_ I prefer to be induced as soon as possible

Once Admitted to Hospital:

_ I would like music in my room

_ I would like my own room

_ I don’t mind if I have to share a room

_ I would like my partner in the room at all times

_ I would like other friends and family in the room at all times

_ I would like the lights dim

_ I would like to have an enema done if necessary

_ I do not want students or residents assisting me

_ I don’t mind if students or residents assist me

_ I would only like minimal vaginal examinations, unless necessary

_ I would rather wear my own clothes

_ I would like to film/take pictures of delivery and labor

_ I would like to eat outside foods, if possible

_ I would like to have a heparin or saline lock

­_ I prefer intermittent monitoring to continuous monitoring

_ I prefer continuous monitoring to intermittent monitoring

_ I don’t have a preference about monitoring, whatever is best for me and my baby

Induction:

I would prefer one or more of the following ways to induce labor:

            _ breast stimulation

            _ herbs

            _ walking or moving around

            _ chiropractic

If medical induction is necessary, I prefer:

            _ prostaglandin gel

            _ pitocin

            _ stripping membranes

            _ rupturing membranes

            _ amniotomy

            _ cytotec (oral or vaginally, whichever method is best)

            _ other: ____________________________

During Labor:

_ I would like the option of returning home if I’m not in active labor

_ I wish to give birth naturally

_ I wish to have a C-section

_ I would like a birthing stool

_ I would like a birthing chair

_ I would like a squatting bar

_ I would like to use stirrups or foot pedals

_ I would like people holding my legs down instead of stirrups or foot pedals

_ I would like a birthing tub/pool

_ I would like to be coached during labor for pushing

_ I do not need to be coached to push

_ I would like to try the following positions:

            _ lying on my side

            _ squatting

            _ semi-reclining

            _ hands and feet

_ I would like my partner in the room with me

_ I would like other family and friends in the room with me

_ I would like a mirror available so I can view the birth

_ I’d rather risk a tear rather than have an episiotomy

­_ I’d rather have an episiotomy rather than risk a tear

_ I would like to touch my baby’s head as it crowns

Pain Relief:

­_ I only want pain relievers if I ask or insist

_ I would like to try acupuncture

_ I would only like medications suggested by my doctor to reduce pain

_ I would like to take a hot shower

_ I would like to try hot/cold therapy

_ I would like to be massaged

_ I don’t want any form of pain relievers

_ I would like to watch TV

_ I would like to listen to music

After Birth:

_ I would like to cut the umbilical cord

_ I would like my partner to cut the umbilical cord

_ I would like another relative or friend to cut the umbilical cord __________________

_ I’d like to hold my baby immediately

_ I would like my partner to have access to my baby at all times, even if I can’t

_ I would like a private room

_ I would like to breastfeed as soon as possible

Baby Care:

_ I would like my baby’s eye care to be handled after a bonding moment, if permissible

_ I prefer immunizations to be done as necessary

_ If there are any problems, I would like my partner to be with our baby at all times

_ If there are any problems, I’d like access to my baby at all times

_ I would like my baby boy circumcised

_ I would not like my baby boy circumcised

_ I would like my baby breastfed only

­_ I would like my baby bottle fed only

_ I do not have a preference on how my baby is fed

_ Routine PKU testing is okay

_ I would like to wait until later for my baby to be PKU tested

Leaving Hospital:

_ I’d like to be discharged as soon as possible

­_ I’d like to be able to stay in hospital until my baby and I are discharged together

_ If my baby is sent to another hospital, I’d like to go with him or her

_ My baby can only leave with me or my partner _________________________

About Me/Other:

_ I am blind or have other vision impairments

_ I am deaf or have other hearing impairments

_ I am currently on these medications

 ____________________________________________________________________

_ I have recently been on these medications

 ____________________________________________________________________

_ I’ve been diagnosed with _________________________________________________

_ I am allergic to _________________________________________________________

_ I am diabetic

_ I have tested positive for Group B Strep

_ My blood type is Rh-

_ My doula’s name is _____________________________________________________

_ My midwife’s name is ___________________________________________________

_ My doctor’s name is _____________________________________________________

_ I’ve had these complications during my pregnancy _____________________________

[Page updated February 2015]