Birth Plan
Before Birth
Birthing Person
First Name
Last Name
Pronouns
Partner
First Name
Last Name
Pronouns
Doula (if applicable)
First Name
Last Name
Care Provider
First Name
Last Name
Place of Delivery (ex: Home or Hospital Name)
Estimated Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pediatrician
First Name
Last Name
Pediatrician Phone Number
-
Area Code
Phone Number
Who would you like to have with you (besides your partner) during labor and/or at delivery. You can include a doula, other children, family, or friend.
*Note: Due to COVID-19, only one person may be permitted in addition to you. Ask your care provider about current policies.
Visits
Other visitors/friends/family permitted during labor
No additional visitors permitted during labor
Other
Medical Students
No medical students
Medical students ok.
I do not want to be touched or have proceeders done by medical students.
Other
Please check the boxes that are important to you.
I prefer to be able to eat and drink during labor.
Have freedom to move, walk, be upright, and out of bed during labor.
Access to a tub for labor.
Personalize the atmosphere with music, lighting, items from home.
Access to equipment - exercise ball, peanut ball, in-room shower.
Practitioners support to use birthing positions.
Limit Cervical Exams
Timed Cervical Exams
Other
Labor & Delivery
What are you envisioning for your labor and birth? Please describe.
Alternatives to pain medication
Hypnobirthing
Nitrous Oxide
Water labor (shower and/or tub)
Comfort measures and calm environment
Other
Epidural or other pain medication use.
No
Do not offer pain medication, I will request it if I want it.
Yes, I will request when I am ready
Other
Fetal Monitoring
Intermittent & External Monitoring preferred (standard for low-risk, no intervention spontaneous labor)
Continuous External Monitoring preferred (standard for inductions, epidurals, medication, high risk, and special scenarios where there is concern)
Please discuss monitoring with me first.
I would like to discuss monitoring options that allow for maximum movement and/or use of water labor
Other
Coached Pushing or Instinctive Pushing
I would like to push when I feel the urge to bear down with my contractions
I would like to be coached when to push
I would like to push on my own intuition with some coaching.
Other
Routine Postpartum Pitocin
Yes, I consent
Only use if necessary
Other
Delivery Support
Warm compress to the perineum
Guidance upon crowning
Other
If I have an epidural
Please help change my position frequently. Examples are side lying with peanut ball/pillow, hands and knees, and throne position.
Discuss which type of catheter will be used (Straight catheter or indwelling)
Newborn Care
Select All That Are Important to You
Holding baby immediately after birth
Golden Hour (allow baby to go through the natural 9 stages)
Partner to cut the umbilical cord
Delay cord clamping
Cord Blood Banking
Postpone weighing the baby and newborn care proceedures until baby and I have greeted each other.
Other
Please list any additional information you feel is important to know for your birth experience. This is place where you can write about additional wants, past traumas, etc.
Please do not say... (examples of language that you feel may not be helpful to you)
Please say this... (examples of language or affirmations that may help you feel confident, safe, and supported)
Vitamin K Shot
No
Yes
Other
Hep B Shot
Yes
No
Plan to have pediatrician administer
Other
Eye Ointment
No
Yes
Other
Circumcision
No
Yes, in hospital.
Yes, outside of hospital
N/A
Other
Bathing
No
Yes, in hospital by staff.
Yes, parent led with staff assistance.
Yes, please show us how to bathe our baby
Other
Rooming In
Baby is to stay in my room.
Baby may go to the nursery upon my request
Other
Emergency and Cesarean
Please check the boxes that are important to you.
Partner to accompany me to cesarean birth.
Doula to accompany me to cesarean birth.
Events explained to me as they are happening.
Skin-to-Skin as soon as possible.
If I am unable to hold the baby, my partner will hold/skin to skin.
If a clear screen is available, I would like it to be used to see my birth.
Other
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