BIRTH PLAN TEMPLATE

GENERAL INFORMATION:
Birth Plan for: ___________
Mother's first and last name:___________
Father's first and last name:___________
Due Date:___________
Coach's first and last name:___________
Other support people:___________
Name of obstetrician:___________
Desired hospital:___________


EARLY/FIRST STAGE LABOR
Environment
Low lighting
Quiet room
Music
Wear own clothing
Coach/partner only desired attendees other than medical staff
I would prefer to wear my contact lenses/glasses
I want my labor and delivery photographed/video recorded
I do not want my labor and delivery photographed/video recorded
Other___________


Mobility
choose one:
Unlimited freedom to move (walking, bathroom, rocking chair, fitness ball, etc.)
Mobility is not important to me


Shaving/Enema
{most hospitals no longer shave the pubic area or use enemas, but just in case...}
I would like to avoid the use of an enema.
I would like to avoid having my pubic area shaved.


I.V.
I.V. insertion is acceptable at any point
I.V. placement should be attempted only if dehydration occurs
Please attempt to insert I.V. on left/right (circle)


Hydration
No restrictions
Clear fluids
Ice chips
IV


Monitoring
choose one:
Intermittent monitoring (Fetoscope, Doppler, etc.)
Continuous monitoring (External leads, internal monitoring)
No monitoring except in emergency situations


Catheritization
I would like to avoid catheterization unless it is absolutely necessary

Pain Relief Offer
choose one:
Do not offer; I will ask if I desire it
Offer if I appear uncomfortable
Offer as soon as possible


Pain Relief Options
Natural
Relaxation techniques
Hot or cold compresses
Positioning
Water therapy (bath, whirlpool, shower)
Massage
Accupressure
Hypnotherapy


I.V. Medication
Stadol
Nubain
Demerol
Other ______________________________


Epidural
Walking epidural
Traditional epidural


Labor Induction/Augmentation
No induction
No augmentation
Cervical gel
Pitocin
Rupturing of the amniotic sac
I prefer my amniotic sac be allowed to rupture on its own


SECOND STAGE LABOR
Pushing
{check all pushing options which are acceptable}
Push in position of my choosing
Squat/Birthing Bar
Pushing while on hands and knees
I am not concerned with positioning
Foot pedals rather than stirrups
People as leg support rather than stirrups
Spontaneous pushing (when I feel the need)
Pushing with medical direction


Delivery
I would like to touch baby's head when it crowns
I would like a mirror available to view pushing/crowning/birth


IMMEDIATELY FOLLOWING DELIVERY
I want baby placed on my chest immediately after birth
I would like my partner/coach to cut the cord
I would like to cut the cord
Partner/coach does not want to cut cord
Please delay cord clamping and cutting until pulsating ceases
I would like to hold the baby while delivery placenta
I do not wish a pitocin injection to assist with placenta delivery
I wish baby to be examined in my presence.
If baby cannot be examined in my presence, I wish my partner/coach to remain with baby at all times
I do not wish baby to be placed under heat lamps; I will hold baby and provide body warmth instead
I want to donate cord blood
I want to bank cord blood


EPISIOTOMY
I do not want an episiotomy unless there is an emergency situation
I would like to attempt perineal massage to stretch the perineum.
I would like an episiotomy to reduce risk of tearing
I would like a local anesthetic during repair of tear/episiotomy
I would not like a local anesthetic during repair of tear/episiotomy


BABY CARE
I wish to breastfeed exclusively
I wish to breastfeed, but formula supplementation is acceptable
I wish to formula feed
I do not want baby to be given a pacifier
I would like to meet with a lactation consultant as soon as possible
I want baby circumcised
I do not want baby circumcised


PRIVACY
I would like a private room, I understand that there will be an additional charge
I would like baby to "room in"
I would like baby to sleep in nursery
I would like baby to be brought to me for all feedings
I welcome all well wishers
I wish to limit visitors
I would prefer my door closed with a sign requesting that visitors and staff members knock before entering
I do not wish to have medical students involved in my care
Other ______________________________


CESAREAN
In the event that a cesarean section is deemed necessary, I would like the following:
Partner/coach present
Other support present _________________________
Pictures/video
Screen lowered at delivery
I would like the procedure described as it is happening
Partner would like to cut cord
Other _________________________


In the Event that Baby Requires Special Care Due to Trauma or Illness:
I would like to breastfeed/pump breast milk
Partner/coach will accompany baby if transferred to another hospital
I would like to be transferred to baby's hospital


Mother's Signature ______________
Date ____________

Father's Signature _______________
Date ____________


With a well-considered, well-organized plan in place you'll relieve stress by knowing what to expect and by ensuring that your wishes and preferences are known to all - including your doctor.