Free with Services
Full name: ________________________ Partner’s name: __________________
Today’s date: __________________ Due date/Induction date: _______________
Doctor’s name: ___________________ Hospital name: _____________________
Please note that I: My delivery is planned as:
___Have group B strep ___Vaginal ___VBAC
___Am Rh incompatibility with baby ___C-section
___Have gestational diabetes ___Water Birth
___Other children: ____________________________________________________
…present before AND/OR during labor
During labor I’d like… ___Music played (I will Provide) ___To wear my own clothes
___The lights dimmed ___To wear my contact lens the entire time
___The room as quiet as possible ___My partner to film AND/OR take pictures
___As few interruptions as possible ___My partner to be present the entire time
__As few vaginal exams as possible __To stay hydrated with clear liquids & ice chips
___Hospital staff limited to my doctor & nurses __To eat and drink as approved by my doctor
(no students, residents, or interns present)
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 guests to be present (i.e.. no residents, medical students, or other hospital personnel)
___To wear my contact lenses, as long as I don’t need a c-section
___To eat if I wish ___Try to stay hydrated by drinking clear fluids instead of an IV
___To have a heparin or saline lock ___To walk and move around as I choose
I’d like to spend the first stage of labor: I’m not interested in:
__Standing up __An enema
__Lying down __Shaving of my pubic area
__Walking around __A urinary catheter
__In the shower __An IV, unless I’m dehydrated (and a
__In the bath heparin or saline lock IS/IS NOT okay)
I’d like fetal monitoring to be:
___Intermittent ___Performed only by Doppler
___Internal ___Performed only if the baby is in distress
I’d like labor augmentation:
___Performed only if baby is in distress ___Performed with Pitocin
___First attempted by natural methods such ___Performed by rupture of the membrane
as nipple stimulation ___Performed by stripping of the membrane
___Performed by membrane stripping ___Performed with prostaglandin gel ___Never to include an artificial rupture of the membrane
For pain relief I’d like to use:
___Breathing techniques/distraction ___Standard epidural
___Cold/Hot therapy ___TENS
___Demerol ___Walking epidural
___Massage ___Please don’t offer me pain medication
___Whatever is suggested at the time only what I request at the time
If I decide I want medicinal pain relief, I’d prefer:
___Regional analgesia (an epidural and/or spinal block)
During delivery I would like to:
___Squat ___Use people for leg support ___Semi-recline
___Lie on my side ___Use foot pedals for support ___Be on my hands and knees
___Stand ___Use birth bar for support ___Use birthing stool
___Lean on my partner ___Be in birthing tub ___Be in the shower
___Whatever feels right at the time Other_____________________________________
I will bring a:
___Birthing stool ___Squatting bar
___Birthing chair ___Birthing tub
As the baby is delivered, I would like to:
___Push spontaneously ___Push as directed ___Push without time limits, as long as
___Use a mirror to see baby crown baby and I are not at risk
___Touch the head as it crowns ___Let the epidural wear off while pushing
___Have a full dose of epidural ___Avoid forceps usage ___Help catch the baby
___Avoid Vacuum extraction ___Let my partner catch the baby
___Let my partner suction the baby ___Use whatever methods my doctor deems necessary
I would like an episiotomy:
___Used only after perineal massage, ___Performed as my doctor deems necessary
warm compresses and positioning ___Performed with local anesthesia
___Rather than risk a tear ___Performed by pressure, without local anesthesia
___Not performed, even if it means risking a tear ___Performed only as a last resort
___Followed by local anesthesia for the repair
If a C-section is necessary, I would like:
___A second opinion ___My hands left free so I can touch the baby ___To stay conscious
___To make sure all other options have been exhausted ___An epidural for anesthesia
___The surgery explained as it happens ___The screen lowered so I can watch baby come out
___My partner to remain with me the ENTIRE time
___My partner to hold baby as soon as possible ___To breastfeed in the recovery room
Cord Blood Banking
I’m planning to:
___Donate cord blood to a public bank ___Bank cord blood privately ___Neither
Immediately after delivery, I would like:
___My partner to cut the umbilical cord ___To deliver the placenta spontaneously
___The umbilical cord to be cut only after it without assistance
Stops pulsating ___To see the placenta before it is discarded
___Not to be given Pitocin/oxytocin after I deliver the placenta unless it’s necessary
I would like to hold baby: I would like to breastfeed:
___Immediately after delivery ___As soon as possible after delivery
___After suctioning ___Before eye drops/ointment are given
___After weighing ___Later
___After being wiped clean and swaddled ___Never
___Before eye drops/ointment are given
I would like my family members:
___To join baby and I immediately after delivery ___To join baby and I in the room later
___Only to see baby in the nursery ___To have unlimited visiting after birth
I would like baby’s medical exam & procedures:
___Given in my presence ___Given only after we’ve bonded
___Given in my partner’s presence ___To include a heel stick for screening tests
___To include a hearing screening test beyond the PKU
___To include a hepatitis B vaccine ___ Nothing my physician will take care of it
Please don’t offer my baby:
___Vitamin K ___Antibiotic eye treatment ___Sugar water
___Formula ___A pacifier
I’d like baby’s first bath given: I’d like to feed baby:
___In my presence ___Only with breast milk
___In my partner’s presence ___Only with formula
___By me ___On demand
___By my partner ___On schedule
___With help of a lactation specialist
I’d like baby to stay in my room: I’d like my partner:
___All the time ___To have unlimited visiting
___During the day ___To sleep in my room
___Only when I’m awake
___Only for feeding
___Only when I request
If we have a boy, a circumcision should:
___Be performed ___Not be performed ___Be performed later
___Be performed with anesthesia
___Be performed in the presence of me AND/OR my partner
As needed post-delivery, please give me: After birth, I’d like to stay in the hospital:
___Extra-strength acetaminophen ___As long as possible
___Percoset ___As briefly as possible
___Stool softener ___Wait to see how I feel before deciding
___Laxative about the timing of hospital discharge
If baby is not well, I’d like:
___My partner and I to accompany it to the NICU or another facility
___To hold him/her whenever possible ___To breastfeed or provide pumped breast milk
A few important notes
The reason for creating a birth plan is so that everyone understands your hopes and desires for labor and birth. It is a great place to begin discussions with your caregiver(s). This is not a contract, but a statement of your preferences.
Birth plans are best kept short and to the point -- lots of details may be lost on medical support staff. You may wish to create two plans: one for you and your support team (coach, doula, etc.) and another, more concise document (about a page long) for your caregiver and the hospital/birth center staff. It is very important that you talk about the procedures and/or choices that appear your plan with your caregiver(s). Not only do obstetric practices often vary by caregiver, hospital, state and country, there are often important factors involved. It is your responsibility to evaluate and understand each choice you make.
Instructions: On the plan below, all section headings are checked by default. If you do not select any of the options underneath a particular heading (and keep the blank boxes clear), uncheck the heading box in order to avoid having a spare heading with no additional text.
When you're done, press the "create" button at the end of the page! Save the finished plan to your hard drive as a .htm or .html file or print it out.
Start here Opening Statement can be like this:
To Whom it may concern:
We are looking forward to sharing our birth experience with you. We have created this birth plan in order to outline some of our preferences for birth. We would appreciate you reviewing this plan, and would be happy to do so with you.
We understand that there may be situations in which our choices may not be possible, but we hope that you will help us to move toward our goals as much as possible and to make this labor and birth a great experience.
We do not want to replace the medical personnel, but instead want to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Please feel free to ask if you have any questions or comments. Thank you!
Birth plan title:
Our wishes for Childbirth
My wishes for Childbirth
Preferences for Labor and Birth
Our Birth Choices
Your full name: Name of your caregiver: Name of Hospital/Birth Center: Due date: Coach/main support (i.e. my husband, my coach, James, my mother): How do you want the plan to refer to your baby? (our baby, my daughter, the babies) Date:
Introduction: (please feel free to modify/delete any of this text)
We are looking forward to sharing our birth experience with you. We have created this birth plan in order to outline some of our preferences for birth. We would appreciate you reviewing this plan, and would be happy to do so with you. We understand that there may be situations in which our choices may not be possible, but we hope that you will help us to move toward our goals as much as possible and to make this labor and birth a great experience. We do not want to replace the medical personnel, but instead want to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Please feel free to ask if you have any questions or comments. Thank you!
I have tested positive for Group B Strep.
My bloodtype is Rh- (Rhesus Negative).
I have gestational diabetes.
I am diabetic.
I am hard of hearing.
My vision is impaired.
I would like to wear contact lenses or glasses at all times when conscious.
Please perform no routine preparatory tasks (shaving, enema, etc.), unless requested.
I would like to have an enema upon admission to the hospital.
I expect that doctors and hospital staff will discuss all procedures with me before they are performed.
I would like to be free to walk, change positions and use the bathroom as needed or desired.
I prefer to wear my own clothes, rather than a hospital gown.
I prefer to eat and drink throughout labor, as desired.
I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips).
So I can stay as mobile as possible, I would prefer to have a heparin lock adminstered instead of an IV.
Please do not administer an IV or heparin lock unless there is a clear medical indication that such is necessary.
I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions.
I would like to play my own music.
Please limit the number of vaginal exams.
I wish to labor freely in the birthing tub or shower.
As long as the baby is doing well, I prefer that fetal heart tones be monitored intermittently with an external monitor or doppler, even if the membranes have ruptured.
If fetal distress is suspected and time permits, I would like confirmation of this with a fetal scalp blood sample before proceeding with other interventions.
Please allow me to vocalize as desired during labor and birth without comment or criticism.
I do not mind observation by students, interns or staff.
Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.
To preserve my privacy and dignity, I would prefer that everyone knock before entering.
Notes: Labor Induction/Augmentation
I would like to avoid induction unless it is medically necessary.
As long as the baby and I are healthy, I do not want to discuss induction prior to 42 weeks.
If my pregnancy progresses past 40 weeks, I would prefer to base the decision to induce on the results of the baby's biophysical profiles, not on my own personal discomfort or impatience.
I would like to try alternative means of labor augmentation, like walking or nipple stimulation, before pitocin or artificial rupture of membranes is attempted.
If induction is necessary, I would like to attempt it with prostaglandin gel or another means before pitocin is administered.
If induction is attempted, but fails, I would like to come back at another time rather than pursue further intervention (assuming my membranes are intact and that waiting presents no danger to the baby or myself).
Please do not rupture my membranes artificially unless medically indicated.
Please do not offer anesthesia/analgesia unless I ask for it.
If I ask for pain relief, please feel free to offer non-medical choices for coping and/or remind me how close I am to the birth.
I would like to avoid all narcotics, if possible.
I prefer an epidural to narcotic pain medication.
If pain relief is considered, I would like to try a narcotic before an epidural.
I would like to try having narcotics-only administered in the epidural line before progressing to full anesthesia.
I would like to have an epidural as soon as permissable.
I would like to have the epidural catheter placed upon my admission to the hospital.
I would like to have a light dose (walking) epidural.
I would like the epidural to wear off slightly as I approach full dilation and the pushing stage.
Cesarean Section Delivery
I feel very strongly that I would like to avoid a cesarean delivery
If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making.
I would like (coach) to be present during the surgery.
Please explain the surgery to me as it happens.
I would prefer general anesthesia in an emergency only.
I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.
I would prefer spinal anesthesia for the procedure.
I would like to have a respectful atmosphere without chatter during any part of the surgical procedure.
If possible, please do not strap my arms to the table during the procedure.
If conditions permit, I would like to be the first to hold the baby after the delivery.
If possible, I would like to breastfeed the baby immediately after the birth.
If conditions permit, the baby should be given to (coach) immediately after the birth.
I would like our plans outlined here for after the birth to be followed as closely as possible.
Please lower the screen just before delivery so I may see the birth of the baby
I prefer not to have an episiotomy unless it is medically indicated.
To avoid episiotomy or tearing, (coach) or my labor assistant will perform perineal massage with oil and apply hot compresses.
To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.
I would rather tear than have an episiotomy.
I would rather have an episiotomy than risk a tear.
Please administer local anesthesia when repairing any episiotomy or tear(s).
Please suture tears only if necessary.
Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase.
I prefer to push or not push according to my instincts and would prefer not to have guidance or coaching in this effort.
I do not want to use stirrups while pushing.
I would like the freedom to push and deliver in any position I like.
I would appreciate help from (coach) and staff supporting my legs as I push.
I would like to deliver in a birthing pool and have made arrangements to rent one for the birth.
I would like to have a mirror available and adjusted so I can see the baby's head crowning.
I would like the opportunity to touch my baby's head as it crowns.
I would like a soothing environment during the actual birth, with dim lights and quiet voices.
I would like (coach) to help catch the baby.
I would like (other) to help catch the baby.
I would like to help catch the baby.
I would like to have the birth recorded with photographs, video tape and/or tape recording.
Please place the baby on my stomach/chest immediately after delivery.
I would like to breastfeed the baby immediately.
(coach) would like the option to cut the cord.
(other) would like the option to cut the cord.
I would like the option to cut the cord.
Please allow the umbilical cord to stop pulsating before it is cut.
I have made arrangements for donation of the umbilical cord blood.
I have made arrangements to bank the umbilical cord blood.
I prefer to wait for spontaneous delivery of the placenta and do not want a routine injection of pitocin.
Please show me the placenta after it is delivered.
Please remove my IV/Heparin lock/catheter as soon as possible after delivery.
I would like to hold the baby skin-to-skin during the first hours to help regulate baby's body temperature.
I would like to hold the baby through delivery of the placenta and any repair procedures.
Please evaluate and bathe the baby at my bedside.
If possible, please evaluate the baby on my abdomen.
If the baby must go to the nursery for evaluation or medical treatment, (coach), or someone I designate, will accompany the baby at all times.
I would prefer to bathe the baby myself, at my discretion.
Please delay eye medication for the baby until we are well past the initial bonding period (a couple hours after the birth).
If available, would prefer erythromycin eye treatment or other antibiotic eye drops instead of silver nitrate.
I would like to waive the administration of eye antibiotics.
I would prefer to have Vitamin K administered orally.
I would like to waive the administration of routine Vitamin K, unless medically indicated.
I would like to defer the PKU screening.
I would like to defer the following vaccinations:
Postpartum (Click here for postpartum features)
I would prefer not to be catheterized until I've had some private time to attempt urination on my own.
If available, I would prefer a private room.
I would like to have the baby room-in with me at all times.
Once I've had time to recover, I would like the baby to room-in with me.
I would like the baby to room-in with me during the day, but stay in the nursery at night.
I would like the baby in the nursery at night, but brought to me for breastfeeding on demand.
I would like the baby in the nursery and brought to me on request and for breastfeeding.
I would like my (coach) to room-in with me.
I would like (other) to room-in with me.
I would like my other children to have free visitation access.
Assuming I feel up to it and the baby is healthy, I would like to be released from the hospital as soon as possible following the birth.
I would like permission for access to my chart and the baby's chart.
Breastfeeding (Click here for information about breastfeeding)
I plan to breastfeed and want to nurse immediately following the birth.
Please do not give the baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity.
Unless I am unable to give my consent, please do not give the baby any supplements without first informing me of the reason(s) and seeking my consent.
Please do not give the baby a pacifier.
I would like to know more about breastfeeding.
I would like to meet with the staff lactation consultant.
I do not plan to breastfeed.
I would like to take still photographs during labor and the birth.
I would like to make a videorecording of labor and/or the birth.
I am not planning to have the baby circumcised.
I am planning for the baby to be circumcised before we check out of the hospital. (Note: Do not waive Vitamin K shot in this event)