Birth Plan Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
During Labor
*
No Medication
Free Movement
I Choose Positions
Limited Cervical Exams
Pitocin Only if Necessary
No Pitocin by Any Means
Vaginal Birth
Cesarean Birth
VBAC
Lotus Birth
No Forceps or Vacuum
No Episiotomy
Music
Aromatherapy
Other
After Labor
*
Immediate Skin-to-Skin
Delayed Cord Clamping
Save Placenta
Partner Cuts Cord
Breastfeed Immediately
No Vitamin K Shot
Oral Vitamin K, if available
No Hepatitis B
No Pacifier
Delayed Eye Ointment
Delayed First Bath
Other
Do you have any other requests? If so, list below.
Submit
Should be Empty: