Earth Mama's Free Birth Plan

Personal Information
Name*
Email*
Due Date

MonthDayYear
Date
Name of Primary Support Person
Relationship to Primary Support Person
Phone number of Primary Support Person
Name of Additional Support Person
Additional Support Person Relationship
Phone number of additional Support Person
Provider
Provider's Phone Number
Family and friends who may be in my room at any time
During My Pregnancy

Questions to ask your provider.
When should I start to feel movement?How do I get to know my baby's unique fetal movement pattern?What steps should be taken urgently if there is a change in fetal movement (decrease or increase in frequency, pattern, or strength), including where to go, how to get care, and what will be done?How can I get additional fetal monitoring and ultrasounds if I am concerned about my baby?When/how often will you monitor my baby's growth in each trimester?When/how often will you monitor my baby's placental function, volume and cord flow in each trimester?What urgent warning signs in maternal or fetal health should I watch for, and how can I quickly obtain the necessary care?What can I do to lower the risk of adverse outcomes like stillbirth, maternal and infant morbidity/mortality, prematurity, and birth injuries or trauma?How many hours is it safe to continue laboring without intervention?
Before Labor Begins
I would prefer to wait until 40 weeks before considering inducing labor, provided there are no indications of fetal or maternal distress, or issues with the placenta or umbilical cord or baby's growth.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.If I go past my due date and the baby and I are fine, I would like to discuss induction or C-section.Please obtain my permission and discuss the pros and cons of 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 ruptured 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.I would like to be admitted as soon as contractions start for fetal monitoring.I would like to request that an on-call provider of the same racial/ethnic background as me be available for my birth.
Induction

I am open to discussing pros and cons of:
Breast stimulationWalkingHerbsEnemaCastor oilChiropracticAcupunctureSexual intercourseStripping membranesProstaglandin gelsPitocinRupturing membranes
Pain Management
What are my pain management options?Please only offer pain medications if I ask for them.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.
If available, I would like access to the following alternative pain management techniques:

Guided breathing techniquesDeep (or guided) relaxationAcupressureAcupunctureMassageChiropracticHypnotherapyVisual imaging workWater/bath/showerPerineal massage
Vaginal Labor & Delivery
I would like a birthing room.I would like a delivery room.I would like a room with a shower and/or bath.I would like to deliver at home.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 to feel unrestricted to chant, grunt, or moan during labor.Ideally, I want to be able to walk around and move as I wish while in labor.Please always keep my door closed while I am in labor.I would like to have my birth photographed or filmed.If pushing for more than several hours, I am open to discussing options for medical intervention.I prefer to have no episiotomy and risk tearing, unless I am having a medical emergency.If possible, please allow the shoulders and body of my baby to born spontaneously.Please, no residents or students attending my birth.
Labor Positions
SquattingClassic semi-reclineHands and kneesOn the toiletStanding uprightSide LyingOn a round/peanut ballIn the showerIn a birthing tubBirthing bedBirthing stoolSquatting bar
The Delivery
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 them onto my abdomen as right away.I would like my partner to catch my baby.I would like for our baby to hear our voices first.For spiritual or religious reasons, I would like the room to be totally silent as the baby is born.I prefer to have the lights dimmed for delivery or, if it is daylight, to access only natural light.
Cesarean (C-Section)
I would like to understand the pros and cons of a C-section.If a C-section is not an emergency, please give my partner and me time alone to think about it.Under what circumstances would you advise an emergency C-section?I would like my partner to be present at all times during the C-section, if possible.I would like to remain conscious during the procedure, if possible.Please discuss with me what I can expect to feel immediately following the procedure.We would like to have the option to photograph or film the birth.I prefer to have a gentle C-Section.Please respect my wishes to be quiet during the operation (e.g., avoiding small talk with other practitioners in the room).If time allows, please discuss anesthesia options with me.I prefer a low transverse incision on my abdomen and uterus.If my baby is healthy, I would like to hold them 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 them (i.e., holding, skin-to-skin contact, etc.).Please pay special attention to our nursing needs in recovery as I may need some extra help nursing after the procedure.Please discuss my post-operative pain medication options with me before or immediately following the procedure.
After Delivery
As long as my baby is healthy, I would like them placed immediately skin-to-skin.Please wait for the umbilical cord to stop pulsating before it is clamped.Please allow my partner to cut the umbilical cord.Please weigh, measure, and observe the placenta and cord, and send to pathology.I would like to bank my baby's cord blood and have made arrangements for this procedure prior to the birth.I would like the option of taking the placenta home.Please place my baby on pulse oximetry after 24 hours of life to rule out any obvious heart conditions present at that time, as recommended by the federal government, American Academy of Pediatrics and American Heart Association.
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 all newborn routine procedures to be performed right away.I would like to have routine newborn procedures delayed until bonding and breastfeeding have occurred.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.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.Vaccinate my baby according to normal procedures.I do not want my baby to receive vaccinations immediately.I would like my baby to be circumcised.Please use a local anesthetic for circumcision.Please do not circumcise my baby.Please do routine PKU Testing after 24 hours.We would like to wait, and delay the PKU testing.My baby is to be exclusively breastfed.I would like to see a lactation consultant as soon as possible for further recommendations and guidance.My baby is to be formula-fed exclusively.I would like to combine breastfeeding and formula feeding.
My Hospital Stay
I prefer to have my support person 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 hospital stay to be as long as medically necessary.I would like my hospital stay to be as short as possible.I would like visitors.I do not want visitors.
If my baby needs to be admitted to the NICU or transported to a different hospital:

I would like to be transported with my baby, if possible.I would like my partner to go with the baby.I would like to be offered a room at the hospital for the duration of my baby's stay, if possible.I would still like to breastfeed or express my milk for my baby during their stay.
My Baby's Healthcare Needs
If there are any other topics specific to my or my baby's healthcare needs, please discuss it with me.
Special Considerations
This is a pregnancy after loss.This is a pregnancy after a stillbirth.This is a pregnancy after a miscarriage.I have experienced infertility.I have experienced previous birth trauma.I have experienced other challenges I wish to discuss.
I would like to discuss specific preferences related to:
How to refer to my pregnancy and previous loss.How to address and ask me about my medical history.Communication during ultrasounds, monitoring, or potential changes to medical treatments.My choice of providers and birthing rooms.
Get more helpful research-based tips and resources from the team at PUSH for Empowered Pregnancy: pushpregnancy.org/tips.
Additional Notes
Should be Empty:

Personal Information

During My Pregnancy

Before Labor Begins

Induction

Pain Management

Vaginal Labor & Delivery

Labor Positions

The Delivery

Cesarean (C-Section)

After Delivery

Newborn Procedures

My Hospital Stay

My Baby's Healthcare Needs

Special Considerations