Birth Plan

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Step 1 of 3

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First Name*

Last Name*

Email Address*

Due Date

Month

Day

Year

Date of Birth

Month

Day

Year

My Labor Support Team

Name

Relationship

Name

Relationship

Name

Relationship

Preference

I prefer to be paired with a nurse that enjoys supporting unmedicated birth.

I prefer female providers (if possible)

I prefer to not have medical students participate in my care.

Admitting

I will stay hydrated on my own and do not want IV fluids unless medically indicated

I do not want to have an IV port placed unless medically indicated

I will wear my own clothes in labor instead of a hospital gown

Pain Management

I have learned about the different ways to cope with pain during labor and would like to try:

Natural coping methods (shower/tub, massage, birth ball, breathing, movement, etc.)

Please do not offer me pain medication, I will ask for it if needed

I want to see how it goes. I would like to use natural ways to cope with labor and may decide to use pain medication, too.

I would like to use IV pain medication (narcotic/Fentanyl)

I would like to use nitrous oxide

I would like to have an epidural

Monitoring My Baby

I prefer to have my baby monitored when necessary, but not all the time

I prefer to monitor my baby all the time. I understand this will limit my movement and may keep me in bed during labor

I prefer a portable monitor (If available and if conditions allow me to move freely)

Labor Progress

I prefer to limit cervical exams

Giving my body extra time to make progress as long as my baby and I are OK

Using non-medicine ways like breast stimulation and walking

Breaking the bag of water

Using Pitocin (medication given in an IV)

Infant Feeding

I plan to exclusively breastfeed my baby

I would like help with breastfeeding from a lactation consultant/nurse

If my baby needs formula or a pacifier for a medical reason, I would like to be informed first

Pushing & Birth

I prefer to push instinctively and not be asked to hold my breath if laboring without an epidural

I prefer to push in a variety of positions (side-lying, squatting, kneeling)

Please help me avoid tearing with warm compress and guidance during crowning

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 help catch my own baby

I would like_________________ to help catch the baby

I would like _________________ to announce the sex of the baby

I plan to take my placenta home

Please show me my placenta

I would like_________________ to help catch the baby

I would like _________________ to announce the sex of the baby

If everything is OK with my baby I would like:

To wait until the cord stops pulsing before cutting ________________ to cut the umbilical cord

My baby placed skin-to-skin right away

To wait until the cord stops pulsing before cutting ________________ to cut the umbilical cord

Baby Care

I would like to delay non-urgent procedures (like weighing and measuring) until after an hour of skin-to-skin contact

If my baby is a boy, I would like him circumcised

If my baby has to leave my side for any reason, I would like______________to stay with the baby

I prefer to skip the baby bath

I would like my baby in the room with me throughout my hospital stay

I would like to try breastfeeding within the first hour of the birth

If my baby has to leave my side for any reason, I would like______________to stay with the baby

I would like my baby to receive the following medications:

Vitamin K

Antibiotic Eye Ointment

Hepatitis B Vaccination

Cesarean Birth

I would like the following person in the OR with me: _________________________

Help me see my baby be born during the surgery by using a clear drape, or lowering the drape

I would like my baby placed skin-to-skin while we are in the OR if we are both doing well

I would like to hold my baby skin-to-skin during the recovery

I would like the following person in the OR with me: _________________________

Additional Requests:

Notes

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