Birth Plan

Create your own custom birth plan. Fill in the form below and we'll create an easy printable birth plan for you to use.

General Information 
 
Name:
Partner's Name:
Doula/labor assistant:
Due Date:
   
Allergies:
Blood Type:
Rh Factor:
   
Health Care Provider Name:
Hospital/Birthing Center where you plan to deliver:
   
Labor induction/augmentation
 
If I go past my due date and there are no health risks for me or my baby, I would prefer
not to be induced to be induced
 
I would prefer trying the following methods to induce labor. Choose any of the following.
Stripping or breaking membranes
Prostaglandin gel
Breast Stimulation
Castor oil and/or enema
Herbs
Walking
Sexual intercourse
Pitocin
   
Environment
I would like the following to be present during labor:
I would like the following to be present during actual birth:
I would like to bring music.
I would prefer dim lighting
I would like to wear my own clothes.
I would prefer to stay in one room during labor, birth, and post delivery if available
I would like to be able to film baby's birth.
I would prefer no students to be present.
I would like to be able to walk around, mobility is important to me.
I would prefer a warm bath over walking. Please let me try that if I do not feel up to walking.
   
Equipment
   
I would like the following equipment available to me. If unavailable, I would like to bring them with me, if possible. Please choose any of the following.
Birthing bed  
Birthing ball
 
Birthing stool
 
Beanbag
 
Birthing pool or tub
 
Shower  
   
Preparation
 
I would prefer to be given not to be given an enema
I would like to wear contact lenses if possible.
I would prefer to be able to eat and drink during labor.
I would prefer no IV unless absolutely necessary.
If I need an IV, I would like to use a heparin or saline lock
   
Monitoring
   
I would prefer no monitoring to be done if there are no signs of distress.
I would prefer external monitoring if monitoring is necessary.
I am comfortable using an internal monitor.
   
Anesthesia - Pain medication
I would prefer to try laboring without pain medication. I will ask if I would like something for pain. Please do not ask me.
I would like to try narcotic medications before being offered an epidural.
I would like an epidural.
I would like a walking epidural.
   
First Stage of Labor
 
I do not want to be separated from my partner during labor or birth.
I would like the option of returning home if my labor is not progressing.
I would like no time limits on laboring and prefer labor not to be augmented unless medically necessary.
I would prefer my water not be broken during labor.
I would prefer vaginal exams kept to a minimum.
I would like encouragement throughout labor.
   
Episiotomy
   
I'd prefer not to have an episiotomy.
I'd prefer to have an episiotomy.
   
Second Stage of Labor (pushing)
 
I'd like a mirror present to view birth.
I'd like to be able to touch baby's head when it crowns.
I'd like coach and/or nurse to support my legs when I push.
I'd like to be able to try any position comfortable during pushing.
I would like to wait to push until I feel the urge even if I am fully dilated.
I would like no time limits on pushing.
I would like counting to help me push.
 
After Birth
 
I'd like my partner to catch the baby.
I'd like to have baby placed on my chest immediately after birth.
I'd like to cut the cord myself.
I'd like to have my partner cut the cord.
I'd like to wait on cutting the umbilical cord until it stops pulsating.
My partner does not wish to cut the cord. Please do not ask.
I'd like to have baby's first bath and assessment to be done in my presence.
I would like to see my placenta after birth.
I do not wish to see my placenta after birth. Please do not show it to me.
I would like to bank baby's umbilical cord blood.
I would like to donate my baby's umbilical cord blood.
I would like baby to room in with me.
I would like baby to stay in nursery at night so I can rest.
I would like my partner to stay in the room with me.
I'd like to be discharged as soon as possible.
I'd like to stay as long as possible.
 
Cesarian Section
 
I would like to avoid a c-section if possible.
If c-section is necessary, I'd like my partner present.
I would like to touch baby after birth.
I would like partner to hold baby after birth.
I would like screen lowered so I can view birth.
I would like to film c-section.
I would like to breastfeed baby as soon as possible.
 
Breastfeeding
 
Please choose one of the following:
I would prefer to bottlefeed.
I would prefer to breastfeed.
I would like to breastfeed and bottlefeed.
 
Please choose one of the following
I do not want my baby to have a pacifier.
I would like my baby to have a pacifier. I am aware of the risks for nipple confusion.
 
I do not want my baby given any formula or water.
I do not want my baby to have a bottle. I would prefer cup feeding or finger feeding if supplements are necessary.
I would like to see a lactation consultant.
I would like any gift bags or diaper bags given to have formula removed.
 
Circumcision
 
Please choose one of the following
I do not want to have my baby circumcised.
I would like my baby circumsised in the hospital.
I would like to have baby's circumcision done after discharge.
 
I would like anesthesia used during circumcision.
I would like to be present during circumcision.
 
Additional Comments
 

 


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