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Home : Articles : Childbirth & Labor : Before Childbirth : Create A Birth Plan

5 votes

Create A Birth Plan

Printable Version

Personal Details

First Name:

Surname:

Partners Name:

Primary Healthcare provider:

Hospital / Birth Center:

Due Date:

Labor

	I would prefer to avoid an enema and/or shaving of pubic hair
	I would like to be free to walk around during labor
	I wish to be able to move around and change position all throughout labor
	I would like to be able to have fluids by mouth throughout the first stage of labor
	I will be bringing my own music to play during labor
	I would like the environment to be kept as quiet as possible
	I would like the lights in the room to be kept low during my labor
	I would prefer to keep the number of vaginal exams to a minimum
	I do not want an IV unless I become dehydrated
	I would like to wear contact lenses or glasses at all times when conscious

Other:

Monitoring

	I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby
	I do not want an internal monitor unless the baby has shown some sign of distress

Other:

Labor Augmentation / Induction

	I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring
	If labor is not progressing, I would like to have the amniotic membrane ruptured before other methods are used to augment labor
	I would prefer to be allowed to try changing positions and other natural methods (walking, nipple stimulation) before pitocin is administered

Other:

Anaesthesia / Pain Medication

	I realize that many pain medications exist — I'll ask for them if I need them
	Before considering an epidural, and if the situation warrants, I would like to try an injection of narcotic pain relief (Nubain, Demerol, Stadol or similar)
	I would like to have a standard epidural
	I would like to have a walking epidural (low dose)

Other:

Cesarean

	Unless absolutely necessary, I would like to avoid a Cesarean
	If my primary care giver determines that a Cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows
	If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making processes
	I would like __________ (coach) present at all times if the baby requires a Cesarean delivery
	I wish to have an epidural for anaesthesia
	So I can view the birth, I would like the screen lowered just before delivery of the baby
	If the baby is not in distress, the baby should be given to ___________ (coach) immediately after birth

Other:

Episiotomy

	I would prefer not to have an episiotomy unless absolutely required for the baby's safety
	I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage
	I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch
	If possible, I would like to use perineal massage to help avoid the need for an episiotomy
	I would prefer an episiotomy rather than a tear
	I would like a local anesthetic to repair a tear or an episiotomy

Other:

Delivery

	I would like to be allowed to choose the position in which I give birth, including squatting
	I would like __________ (partner) and/or nurses to support me and my legs as necessary during the pushing stage
	I would like to try to deliver in a hands-and-knees position
	I would like to try to deliver in a squatting position, using __________ (coach) or a squatting bar for support
	I would like a mirror available so I can see the baby's head when it crowns
	I would like the chance to touch the baby's head when it crowns
	Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase
	I would appreciate having the room lights turned low for the actual delivery
	I would appreciate having the room as quiet as possible when the baby is born
	I would like to have the baby placed on my stomach/chest immediately after delivery

Other:

Immediatly After The Delivery

	I would like to have my partner cut the cord.
	I would like to cut the cord myself
	I would prefer that the umbilical cord stop pulsating before it is cut
	I would like to hold the baby while I deliver the placenta and any tissue repairs that are made
	I would like to hold the baby for at least fifteen minutes before (he/she) is photographed, examined, etc.
	I would like to have the baby evaluated and bathed in my presence
	I plan to keep the baby near me following birth and would appreciate if the evaluation of the baby can be done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation
	If the baby must be taken from me to receive medical treatment, __________ (coach) or some other person I designate will accompany the baby at all times
	I would prefer to hold the baby rather than have (him/her) placed under heat lamps
	I do not want a routine injection of pitocin after the delivery to aid in expelling the placenta
	I would like to delay the eye medication for the baby until a couple hours after birth
	After the birth, I would prefer to be given a few moments of privacy to urinate on my own before being catheterized
	I would like to donate the umbilical cord blood if possible
	I would like to bank the umbilical cord blood, and have made arrangements to do so
	I would like to see the placenta after it is delivered

Other:

Postpartum

	I would like a private room, if available
	Unless required for health reasons, I do not wish to be separated from my baby
	I would like to have the baby "room in" and be with me at all times
	I would like to have the baby "room in" after I have had some time to recover
	I would like the baby with me during the day but in the nursery at night
	I would like the baby with me during the day but in the nursery at night, but brought to me for breastfeeding
	I would prefer the baby be kept in the nursery and brought to me upon request
	I would prefer the baby be kept in the nursery and brought to me upon request and for breastfeeding

Other:

Breastfeeding

	I plan to breastfeed the baby and would like to begin nursing very shortly after birth
	Unless medically necessary, I do not wish to have any bottles given to the baby (including glucose water or plain water)
	I do not want the baby to be given a pacifier
	I do not plan to breastfeed the baby
	I would like more information about breastfeeding
	I would like to meet with a Lactation Consultant

Other:

Circumcision

	I do not want the baby circumcised
	I do not wish to have the circumcision performed in the hospital
	I would like the baby to be circumcised before we check out of the hospital

Other:

Photo / Video

	I would like to take still photographs during labor and the birth
	I would like to make a video recording of labor and/or the birth

Other:

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