D2D Birth Plan

1
Birthing Person's Name
First Name
Last Name
2
Text Phone Number
3
Email
example@example.com
4
Due Date Estimated or confirmed
Date
Month
Day
Year
5
Chooising your provider
Obstretician (OB/GYN)
Family doctor
Qualified Midwife (Certified/Licensed)
unsure/undecided
I have not yet received prenatal care
Other
6
Birth PlaceThere are many factors to think about when you decide where to give birth. These may include medical factors, location of preferred provider, where you feel safest, and where you feel most comfortable.
Hospital
Freestanding Birth Center
Home
unsure/undecided
7
Birth Team
Spouse/Partner
Friend
Mother
Doula
unsure/undecided
Other
8
Allow Students
Yes
Unsure/undecided
No
Other
9
Photography
Family
Doula
Paid Photographer
None
Labor
Birth
Postpartum
All
None
10
Induction
Medically-indicated induction
Elective Inductions
Avoid inductions of any kind
unsure/undecided
be informed about the risks and benefits of induction methods vs. waiting
do my own research about whether it is medically necessary
wait for labor to start on its own as long as baby and I are healthy
Try induction methods (next question)
Other
11
Inductions/Augmentation/ways to speed up labor Preferred or may consider
cervical ripening pill (Misoprostol/Cytotec; not FDA approved) (Provider)
Internal cervical ripening gel Cervidil- Medicine to soften/thin out cervix (Provider)
Membrane strip or sweep (during a vaginal exam) (Provider)
Foley bulb catheter (non-medication option to ripen cervix) Catheter with balloon to help cervix open (Provider)
IV Pitocin/oxytocin (provider)
PROM- prelabor rupture of membranes (amniotic sac) or (break waters) (Provider)
Black and Blue Cohosh (has side effects discuss with your provider) (Provider)
walking/moving/stairs to speed up labor (home/birth location)
Warm Shower (home/birth location)
Massage/Chiro Care (Home/birth location)
Labor Ball (figure 8) to engage baby (Home/birth location)
Nipple stimulation and/or pumping (releases natural oxytocin) (home/birth location)
Exercise/Walking/Dancing (Home/birth location)
Having sex/orgasm (reminder: don't insert anything vaginally if your water has broken) (home)
Wait for labor to start to get the hormonal benefits for baby and me, if possible
unsure/undecided
Other
12
GBS + MedicationGroup Beta Streptococcus
Focus on nutrition and a healthy diet and Decline the test.
Accept Test
(+)Decline IV medication during labor and watch baby closely the first few weeks
(+) Accept IV medication during labor and watch baby closely for the first few weeks
(+) Accept IV medication during labor ONLY if risk factors are present such as prolonged rupture of membranes, fever, or premature baby.
unsure/undecided
Other
13
Admission procedures: Make any notes about preferences or requests during admission. Most hospitals expect to get you into bed when you arrive, for monitoring your baby, draw blood work, answer admission questions, and do a vaginal exam. Birth centers tend to be more flexible and require far fewer admission procedures.
I (or my partner) will give my labor nurse a copy of my birth plan right away
I will decline initial IV placement or ask to delay it until fluids/meds are necessary (will sufficiently drink hydration fluids and blood building fluids like bone broth)
I will get as much of the admission process complete before my due date
I will pre-register for the L&D and take a tour around 37 weeks to be more prepared and communicate with the charge nurse again about my communication preferences (needs) and confirm access.
Other
14
IV Fluids and nutrition intake (bring)
Hep Lock/Saline Lock and fluids preferred
No IV unless needed
Drinking (staying hydrated) water/coconut water, electrolyte drinks, juice
light snack items - fruit, granola/protein bars, honey sticks (boost of energy) crackers/pretzels
unsure/undecided
Other
15
Monitoring
Continuous Electronig Fetal Monitoring (EFM) (with strapps around belly)
Intermittent Monitoring or Intermittent Auscultation (IA) (with doppler)
Internal fetal monitoring (electrode on baby's while it is still in the womb)
unsure/undecided
16
Movement Labor Positions Change positions every 30 minutes or so to encourage progress in early labor (Choose positions you will consider trying)
Prefer to stay upright as long as possible (walking/swaying)
Sitting/straddling birth stool and/or toilet
rotations/rock on birth ball
Standing/leaning partner
Stair Climbing
Kneeling on bed or mat over birth chair
Guided One foot up on a chair or stairs, lunge to open pelvis
Increase comfort by self initiated movement
Side lying, with a pillow or peanut ball to open pelvis
Assisted Squats
open knee-chest position on floor/bed
unsure/undecided
Other
17
Comfort Management
IV local pain medication (will require continous fetal monitoring)
Nitrous Oxide (not all hospitals have as an option)
Epidural anesthesia (will require catheter and continuous monitoring)
Hydrotherapy (warm tub or shower)
Patterned Breathing
moving freely (walking, squatting, swaying; changing positions often)
Visualization
Massage, counter pressure on low back
Warm/cool compress (rice bag/heating pad/hot water bottle) back shoulders
Stair Climbing
Exercise
TENS unit (electrostimulation)
Music/Aromatherapy (even if only for those who can hear in the birth space to calm them which can help calm mom)
vocalization (making loud, low sounds to release pressure) Remember** Open soft jaw = open soft cervix
visualization/focus point
Unsure/undecided
Please Do Not Offer Pain Medication until I request it
Other
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Provider and birth support team verbiage and communication (interpreters/support persons and those providing medical care)
Contraction (sign for cramp)
Wave (Sign for wave going up and down)
Rupture membranes (water broke)
release of waters (water released)
asking for consent before doing any procedure or check
explaining things as they happen (with interpreter) Clearly before making decisions/signing
giving me time to ask questions and talk it over before any non-emergency procedure
suggesting positions or techniques for comfort and labor progress
NOT mentioning pain medication unless I request it first
staying nearby throughout labor with a calm, reassuring presence
unsure/undecided
Other
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Relaxation is key: Things I will bring or request to make my birthing room feel comfortable and relaxing. I will try to create an environment of safety and comfort conducive to oxytocin and labor progress by doing the following
birth affirmation list or banner
Request doors to remain closed
positive and encouraging talk only
wear/bring my own labor clothes
play/bring my own music/noise machine etc
use/bring aromatherapy/essential oils
Clothing for labor (options layers)
focal point (ultrasound photo/baby name)
lights down low and flameless candles
Other
20
Trans/Nonbinary/identification verbiage requestFeel free to add your specific pronouns
gender-neutral language
Partner
Non-Pregnant person
Pregnant person
Pregnant parent
laboring person
Breastfeeding parent
Chestfeeding parent
specific anatomical language
medical chart to reflect your pronoun or name (if different from your legal/insurance paperwork)
Other
21
Pushing
receive direction on how to push from my provider
listen to my body to know when and how to push
Encourage me to breathe the baby(s) out
Wait for me to feel the pressure/need/urge to push
see (hand mirror) or touch my baby as she/he makes progress
Undecided/unsure
receive perineal massage and/or warm compress to prevent from tearing
Other
22
Birthing Position
Allow me to birth in a position most comfortable to me
use upright position for gravity assistance and comfort
kneeling
semi-prone
semi-sitting with leg supports
supine with stirrups or leg supports
supported squat
side lying
Other
23
Stretching/Episiotomy/Betadine/other interventions
GIVE PERMISSION before my provider uses episiotomy, forceps or vacuum delivery
Allow perineum to stretch on its own
Give me an episiotomy before tear
Do Not give Episiotomy
No Betadine wash
Betadine was preferred/accepted
Other
24
Vaginal - Catching Baby/Avoid separation
Birthing Parent Catch
Partner/significant other/Spouse catch
Medical Provider Catch
Baby remains with parents
Undecided/Unsure
Other
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If my provider recommends cesarean surgery for birth, I would like to
be informed about the risks and benefits of surgery vs waiting/natural birth
would like to remain awake
would like a hands-free cesarean so I can communicate
do my own research about whether it is medically necessary
be accompanied by my support team when in the operating room/recovery room:
learn about "gentle" or "family-centered" cesarean options at my hospital (including drape down after baby is born)
be told what is happening, or use a clear drape so I can see my baby right away
Other
26
Skin to Skin
I would like to hold my baby immediately. (skin-to-skin)
Perform any checks and procedures while baby is on my chest
Please delay routine procedures until after bonding time
I would like my baby's first bath to wait until we are at home
I would like providers to bathe the baby the first day
I would like assistance bathing my baby
hold my baby after s/he is wiped down and checked
Other
27
Announcement of Sex
Partner/Spouse/Non Birthing Parent/father announce
Birthing person/mother announce
Medical Provider announce
Other
28
Cord Clamping/Cutting
Collect blood for the cord blood bank. (I'll provide the kit)
Wait for the cord to stop pulsing to clamp and cut it. (Delayed cord clamping)
My partner or I will cut/clamp the cord
Provider can cut/clamp the cord
Other
29
Placenta
Active Management of 3rd stage
Allow to expell naturally (need gravity to support this and will require conscious effort)
Pitocin injection after birth to encourage cramping down of uterus
We will take the placenta home
Leave with medical staff
Doula will take placenta for processing
Other
30
Magic HourThe first hour after birth. This period of time is critical for a newborn baby who spent the past nine months in a controlled environment
Limit Interruptions
Lights dimmed
Allow Photography
No Photography
Allow family in immediately
Wait for family to visit until after the first hour
Other
31
Feeding Baby
I would like some quite time and privacy to try and breastfeed on my own first
Do not give my baby any formula or water
Do not give my baby any pacifiers
Please provide formula
Other
32
Male Intact/Circumcision
I would like my son to remain intact
I would like my son circumcized
Unsure/undecided
Other
33
Vitamin K Baby
Yes
No
Unsure/undecided
Other
34
Hep B Vaccine BabyMost out of hospital this deicsion is left to the pediatrician
Yes
No
Unsure/undecided
Other
35
Eye Ointment Baby
Yes
No
Unsure/Undecided
Other
Should be Empty: