Building A Birth Plan Email Personal Information Fullname Phone Email * Partners Name Due Date Doctor's Name Hospital Before Labor Begins (Check the items that align with your birth wishes) Birth Wishes As long as the baby and I are healthy, I would like to go at least 10 to 14 days over my due date before inducing labor. As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy. I would like to discuss laboring at home as long as possible. I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan. If nonstress test observation becomes necessary after my due date, I am flexible and support this procedure. I would like to discuss induction before I reach my due date. If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced. Please obtain my permission before stripping my membranes during a vaginal exam. I prefer to have no vaginal exams until I go into labor. I prefer to have only one vaginal exam on or around my due date. During a vaginal exam, I prefer not to have my membranes broken unless there is an emergency situation. I prefer minimal internal vaginal exams. If I am less than four centimeters dilated, I would like to discuss with my healthcare provider the option of going home. Induction Breast stimulation Walking Herbs Enema Castor oil Chiropractic Acupuncture Sexual intercourse Stripping membranes Prostaglandin gels Pitocin Rupturing membranes Environment Upon arrival at the hospital, I prefer to have my partner with me at all times. Please, no residents or students attending my birth. Partner Name Relative(s) Name(s) Friend(s) Name(s) Doula Name Sibling(s) Name(s) this person in my room at any time Birthing Room Room with a shower and/or bath Delivery room At home Birthing bed Birthing ball Bean bag chair Birthing tub/pool/shower Birthing stool Squatting bar I would like to have dimmed lights. I would like for people entering the room to speak softly. I would like to play music. I would like no one to speak during the actual delivery. I would like to wear hospital clothing. I would like to wear my own clothes during labor and delivery. I would like to be reminded to remove my clothing during the actual delivery. I would like to have a TV available. I would like to have a DVD player or streaming service available. I would like to wear headsets during my labor and delivery. I would like to have my birth photographed. I would like to have my birth filmed/videotaped. I would like to wear my glasses or contact lenses unless removal becomes medically necessary. Pain Relief Please only offer pain medications if I ask for them. Please suggest pain management options for me if you see that I am too uncomfortable to handle the pain. Please discuss pain management options for me as soon as possible. After medical guidance for pain relief, I would appreciate some private time with my partner to discuss which pain management technique or medication I would like to use. Breathing techniques Distraction techniques Hypnotherapy Acupressure Acupuncture Massage Visual imaging work Color therapy Deep (or guided) relaxation Water/bath/shower Walking epidural Classic epidural Sedative Ideally, I want to be able to walk around and move as I wish while in labor. I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor. Please always keep my door closed while I am in labor. Monitoring Continuous fetal monitoring Intermittently monitored to allow for as much mobility as possible Lamaze techniques Bradley techniques Childbirth Hypnosis Other Second Stage Labor As long as the baby and I are healthy, I prefer to have no time limits on pushing. If pushing for more than several hours, I am open to medical intervention in 2nd stage labor. Squatting Classic semi-recline Hands and knees On the toilet Standing upright Side Lying Whatever feels right at the time I prefer to have an episiotomy I prefer to have no episiotomy and risk tearing (unless I'm having a medical emergency) If I need an episiotomy, I prefer a pressure episiotomy. Apply hot compresses Apply oil Use perineal massage Encourage me to breathe properly for slower crowning. If possible, please allow the shoulders and body of my baby to be born spontaneously, on their own. Please use a local anesthetic for repairs. No stirrups please unless I'm having a medical emergency The Delivery It's important to me to push instinctively. I do not want to be told how or when to push. Please tell me when to push I would like to view the birth using a mirror. I would like to touch my baby's head as it crowns. I would like to catch my baby and pull it onto my abdomen as it is born. I would like my partner to catch my baby. I would like the doctor to catch my baby. For spiritual or religious reasons, I would like the room to be totally silent as the baby is born. I would like for our baby to hear our voices first. I prefer to have the lights dimmed for delivery or, if it is daylight, to access only natural light. As long as my baby is healthy, I would like my baby placed immediately skin-to-skin on my abdomen with a warm blanket over it. Please do not separate me and my baby until after my baby has successfully breastfed on both breasts. Please delay all essential routine procedures on my baby until after the bonding and breastfeeding period (i.e., bathing). Cesarean If a C-Section is not an emergency, please give my partner and me time alone to think about it before asking for our written consent. My partner is to be present at all times during the c-section. Ideally, I would like to remain conscious during the procedure. I would like the baby to be shown to me immediately after birth. I would like to have contact with the baby as soon as it is possible in the delivery room. I prefer to have a hand free to touch the baby. We would like to have the option to photograph or film the birth. If possible, please discuss anesthesia options with me. I prefer a low transverse incision on my abdomen and uterus. Please respect my wishes to be quiet during the operation (e.g., avoiding small talk" with other practitioners in the room)." If my baby is healthy, I would like to hold my baby and nurse immediately after birth. I would like to sign any waivers necessary to permit me to be with my baby in recovery. As long as my baby is healthy, I would like my partner to be the baby's constant source of attention until I am free to bond with it (i.e., holding, skin-to-skin contact, etc.). I would like my baby to be sent to the nursery while I am in recovery. Please pay special attention to our nursing needs in recovery. I may need some extra help nursing after the operation. I would like to have my catheter and IV removed ASAP after my recovery period. Please discuss with me what I can expect to feel immediately following the procedure. Please discuss my post-operative pain medication options with me before or immediately following the procedure. Third Stage Labor Please wait for the umbilical cord to stop pulsating before it is clamped. Please allow my partner to cut the umbilical cord. I would like to bank my baby's cord blood and have made arrangements for this procedure prior to the birth. I would prefer for the placenta to be born spontaneously without the use of pitocin, and/or controlled traction on the umbilical cord. I would like to have routine pitocin given to me after the placenta is born. I would like to delay routine pitocin after the placenta is born unless there are any signs of hemorrhaging. I would like the option of taking home the placenta. Newborn Procedures If the baby has any problems, I would like my partner to be present with the baby at all times, if possible. I would like to have routine newborn procedures delayed until bonding and breastfeeding have occurred. I would like all newborn routine procedures to be performed in my presence. I would like all newborn routine procedures to be performed right away. I would like my baby to have eye drops administered immediately after birth. I would like to delay the administration of eye drops until after breastfeeding and bonding has occurred. Please do not administer eye drops to my baby, I am willing to sign a formal waiver if need be. I would like my baby to receive a routine injection of vitamin K immediately after birth. I would like to delay the administration of vitamin K up to 1 hour after birth, after breastfeeding and bonding, unless medically necessary. I would like only the orally administered vitamin K to be given to my baby. Please do not administer vitamin K to my baby, I am willing to sign a formal waiver if need be. I prefer any immunizations be postponed to a later time Immunize the baby according to normal procedures. Please do routine PKU Testing after 24 hours We decline routine PKU testing at the hospital and have made other arrangements for this procedure at a later date this week. We would like to wait, and delay the PKU testing until we are ready to leave the hospital Please bathe my baby after we have had time to bond. Please do not bathe my baby at all. We would like to give our baby his/her first bath using our own non-toxic baby products. Circumcision Please do not circumcise my baby. Please do not retract my son's foreskin. I would like my baby circumcised. Please use a local anesthetic Please delay procedure as long as possible Baby Feeding My baby is to be exclusively breastfed. My baby is to be formula-fed exclusively I would like to combine breastfeeding and formula feeding. Please offer guidance on the issue of formula versus breastfeeding. I would like to see a lactation consultant as soon as possible for further recommendations and guidance. Formula Pacifiers Any artificial nipples Sugar water To breastfeed or express my milk for my baby. To have as much bodily contact with my baby as possible. My Hospital Stay As short as it can be. As long as it can be. I prefer a private room. I prefer to have my partner stay with me for the duration of my hospital stay. I would like my other children (regardless of age) to be allowed to visit with me for as long as they wish or as long as hospital policy permits. I would like my guests to be permitted to stay as long as they wish. I want privacy during my stay and for my guests to limit the time they are visiting me. Mothers Name Signature Date Physician Signature Date Notes
