Our Birth Plan
Name: ____________________________________________
Partner/Husband name: ______________________________
Baby’s sex: □ Girl □ Boy □ we wish not to know!
Baby’s Name:
First:______________ Middle:______________ Last:_______________
Dear Birth Team,
We have written this birth plan because we believe that birth is an incredible, beautiful journey, and we are hoping to have a unique and special birth experience. We hope that even in the event that our birth plan cannot be followed as planned due to unforeseen events, you will guide us toward the birth experience we desire.
*If procedures or medications are proposed, we ask that you discuss them with us and suggest alternative therapies and comfort measures so that we can make well-informed decisions.
*We understand that emergencies can happen, and in the case of an emergency, we understand that the health care team will take the best steps for us and our new baby.
First Stage of Labor
Environment:
□ Dim Lights
□ Peace and Quiet
□ Music
Who will be present for the birth: (please help ensure that only those listed below are present when it is time to start pushing)
1. _______________ 2. _______________
3. _______________ 4. _______________
□ Wear my own clothes □ no preference (Gown)
□ No students, residents, etc.
□ No preference regarding vaginal exams
□ Minimal vaginal exams (I will ask for my cervix to be checked for dilatation)
Mobility:
□ Mobility not important
□ Maintain Mobility (Walking, rocking, up to bathroom, etc.)
□ Freedom to move in bed only (up to the bathroom)
Hydration:
□ No Preference ( I understand that I may be placed on a Restricted diet)
□ No restrictions (I would like to eat and drink whatever I want)
□ No Heparin/saline lock IV preference
□ No Heparin/Saline Lock IV (I realize that I may need to sign a Waiver)
Monitoring:
□ No preference (both external & internal monitoring at birth team discretion)
□ External Electronic Monitor only when I authorize monitoring (I realize that I may need to sign a waiver)
□ No Internal Electronic Monitor (I realize that I may need to sign a waiver)
Pain Relief:
□ Offer as soon as possible
□ Offer if uncomfortable
□ Only if I ask
□ None. I have prepared my support person, and myself and wish to have no pain medication offered unless medically necessary.
Please offer the following pain relief options first, even if I ask for pain relief
Pain Relief Options:
□ Relaxation
□ Positioning
□ Birth Ball, Rocking in chair, Squatting bar
□ Water (Shower or tub)
□ Heat or Cold Therapy
□ Massage
□ Hypnosis
□ Acupuncture
IV medication
□ Nubain
□ Demerol
□ Other: ____________________________________________
Epidural
□ Low dose epidural(Walking Epidural)
□ Classical Epidural
Induction/Augmentation:
□ No preference
This is the order/methods in which I would prefer to induce labor if indicated:
□ Natural Methods…
□ Nipple stimulation
□ Walking
□ Sex
□ Prostaglandin gel
□ Amniotomy
□ Cytotec
□ Pitocin
Second Stage of labor
Pushing:
□ I have no pushing preferences (please advise me)
□ Choice of positions (please encourage these positions)
□ Hands and knees
□ Side Lying
□ Squat/Birth Bar
□ Directed Pushing (please help me push by counting)
□ Spontaneous Bearing Down (Listening to your body and pushing.)
□ I would like a mirror to watch the birth
□ I would like to touch my baby’s head when I am crowning
□ Perineal Care:
□ No preference (episiotomy if indicated)
□ Prefer no episiotomy
□ Local Anesthesia (for repair)
Birth
□ I would like baby placed directly on my chest (skin to skin) Immediately following birth
□ I would like my partner/_____________ to have baby placed on his/her chest immediately following birth
□ Please wipe baby off before placing baby on my chest
□ Please take baby to warmer, wipe baby off, diaper, and wrap in blanket before handing baby to me
□ Please wipe, diaper, wrap, and give baby to ___________________
Cord Cutting:
□_________________ is going to cut the cord
□ Immediate (no preference)
□ Delayed please wait for cord to stop pulsating
Placenta
□ I do not want to see the placenta
□ I would like to see the placenta
□ I would like to touch the placenta
□ I would like to save the placenta
Feeding Baby:
□ Breast feeding only
□ Please leave baby on my chest for the first _____ hours for bonding and first feeding
□ Bottle feeding only
□ Combination
□ No pacifiers or glucose water
Eye ointment, Vitamin k, Hepatitis B Vaccine
□ Delayed
□ None (I realize that I may need to sign a waiver)
□ Immediate
Weighing, measuring, Bathing:
□ Please wait _____ hours before weighing, measuring, or bathing
□ I would like to participate in bathing my baby
_____________ would like to give our baby his/her first bath
□ No preference
Separation:
□ None
□ Delayed (after recovery period)
□ Partial Rooming-In (Baby with mother during day, but not night.)
□ Nursery (baby brought to you on your schedule.)
Circumcision:
□ N/A (I am having a baby girl!)
□ None (we are not having our son circumcised
□ In the Hospital
□ Will be done at pediatrician’s office
□ Use anesthesia
□, and/or _________________ would like to be present
Complications & Cesareans
□ Partner/ _________________ to be present in the operating room
□ Please drop the drape so I can see the birth
□ Partner/ _________________ to cut cord if possible
□ Please allow me to see/touch baby as soon as possible
□ Please allow baby to remain with me or _________________ until after recovery
Other:________________________________________________
_____________________________________________________
