Create A Birth Plan

Create A Birth Plan

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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:

Create A Birth Plan