Sample Birth Plan

Sample Birth Plan Options/Choices

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 about the birth. Of course, if complications arise, your healthcare provider might not follow your plan to benefit the health and safety of you and 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 plan below to help you get started:

Before Labor Begins:

_ As long as it’s permissible, I’d like to wait at least 2 weeks after my due date to induce labor

_ As long as my baby and myself 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 needed

_ I would not like students, residents assisting me

_ I don’t mind if students, 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 rather drink fluids rather than receive an IV

_ I don’t mind receiving an IV versus drinking fluids

­_ I would like to walk around if I wish to

_ I would like to eat outside foods

_ I would like to have a heparin or saline lock

­_ I prefer intermittent monitoring versus continuous monitoring

_ I prefer continuous monitoring versus 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:

_ sexual intercourse

_ breast stimulation

_ herbs

_ walking or moving around

_ chiropractic

_ acupuncture

If medical induction is necessary, I prefer:

_ prostaglandin gel

_ pitocin

_ stripping membranes

_ rupturing membranes

_ amniotomy

_ cytotec (either 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 don’t have a preference of birth

_ 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 like to try the following positions for pushing or birth:

_ side lying

_ squatting

_ semi-reclining

_ hands and feet

_ whatever feels right

_ 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 do not want to be offered any type of pain relievers

­_ I only want pain relievers if I ask or insist

_ I would like to try acupuncture

_ I would only like mediations 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 want all newborn procedures to take place in front of me if possible

_ 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

_ I would like all baby procedures to be delayed until after bonding moments

Baby Care:

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

_ I would like to sign a waiver to avoid administration of eye drops to my baby

_ I prefer any immunizations be postponed

_ I prefer immunizations 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 for my baby to be PKU tested until later

Leaving Hospital:

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

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

_ I understand if I must be discharged, yet my baby has to stay for further evaluation

_ If baby is sent to another hospital, I’d like transportation 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 bloodtype 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 _____________________________

_______________________________________________________________________

This page was last updated on 06/2017
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