My Birth Plan

Birth Plan Worksheet

Regarding labor and birth –
Due Date: 4/5/2011

I'm having a baby and these are my wishes for before, during and post delivery.

ATTENDANTS
I'd like the following people to be present during labor and delivery:

Spouse: ___________________________________________________________
Friend/s: __________________________________________________________
Relative/s: _________________________________________________________
Doula: ____________________________________________________________
Children: __________________________________________________________

AMENITIES
I'd like to:

• bring music
• wear my own clothes during labor and delivery
• take pictures during labor and delivery

HOSPITAL ADMISSION & PROCEDURES
I'd like the option of returning home if I'm not in active labor.

Once I'm admitted, I'd like:
• my partner to be allowed to stay with me at all times
• only my practitioner, nurse, and doula (i.e., no residents, medical students, or other hospital personnel)
• I would prefer to keep the number of vaginal exams to a minimum
• to try to stay hydrated by drinking clear fluids instead of having an IV
• I wish to be able to move around and change position at will throughout labor.

OTHER INTERVENTIONS
As long as the baby and I are doing fine, I'd like to:

• have intermittent rather than continuous electronic fetal monitoring
• be allowed to progress free of stringent time limits and have my labor augmented only if necessary
• I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring.
• I would prefer to be allowed to try changing position and nipple stimulation before Pitocin is administered.
• I do not want any kind of anesthesia offered to me during labor, though I would like it available if I specifically request it.
• Custom note regarding use of an epidural: If I must be induced because I went passed the due date, then give me steroid therapy to increase blood platelet levels
LABOR PROPS
If available, I'd like to try a:

birthing stool
birthing chair
squatting bar
birthing tub

I'd like to bring the following equipment with me:
• Birthing stability ball
• other: ____________________________________________________________

PAIN RELIEF
I'd like to try the following pain-management techniques:

• acupressure
• bath/shower
• breathing techniques/distraction
• hot/cold therapy
• self-hypnosis
• massage
• other: ____________________________________________________________

Please don't offer me pain medication. I'll request it if I need it.

If I decide I want medicinal pain relief, I'd prefer:

• regional analgesia (an epidural and/or spinal block)

PUSHING
When it's time to push, I'd like to:

• do so instinctively
• be coached on when to push and for how long
• be allowed to progress free of stringent time limits as long as my baby and I are doing fine

I'd like to try the following positions for pushing (and birth):

• semi-reclining
• side-lying position
• squatting
• hands and knees
• whatever feels right at the time

VAGINAL BIRTH
During delivery, I'd like:

• I would like the room to be as quiet as possible
• I would prefer not to have an episiotomy unless absolutely required for the baby's safety.
• I would like my husband to help "catch" our baby

After birth, I'd like:

• I would like to hold my baby right away, putting off any procedures that aren't urgent
• I would like to breastfeed as soon as possible
• I do not want to get oxytocin (Pitocin) after I deliver the placenta unless it's necessary
• I would like my husband to cut the umbilical cord

C-SECTION
If I have a c-section, I'd like:

• If my primary care provider determines that a Cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows
• I would like my husband present at all times if my son requires a Cesarean delivery
• If C-section, then I wish to have an epidural for anesthesia
• If my son is not in distress, my son should be given to husband immediately after birth
• the baby to be given to my partner as soon as he's dried, if appropriate
• the screen lowered a bit so I can see my baby being delivered
• to breastfeed my baby in the recovery room

CORD BLOOD BANKING
I'm planning to:

 donate cord blood to a public bank
 bank cord blood privately
 neither

POSTPARTUM
After delivery, I'd like:

• To all newborn procedures to take place in my presence
• To my husband to stay with the baby at all times if I can't be there
• to stay in a private room

I'd like:
• To 24-hour rooming-in with my baby
• I would like

FEEDING ISSUES
I plan to:

• Unless medically necessary, I do not wish to have any bottles given to my baby (including glucose water or plain water).
Do not offer my baby:
• formula
• sugar water
• a pacifier

CIRCUMCISION
If my baby's a boy:

• I want him to be circumcised at the hospital

DISCHARGE
I'd like to:

• be discharged from the hospital with my baby as soon as possible
• wait and see how I feel before deciding about the timing of hospital discharge