LET’S FIGURE OUT YOUR BIRTH PLAN Fill out the form below and I’ll go through it and put together an easy to follow printable birth plan for you and your birth team. Name * First Name Last Name Email * Who would you like present at your birth? Significant Other Family Friends Doula Children Other Check all that apply: I am pregnant with twins I am R-h negative I have group B strep I have gestational diabetes I eat a special diet of: Because of religious reasons, I ... I am allergic to: I am currently taking these medications Other (ex: I suffer from anxiety) Labor Preferences Check all that apply To go home if I am less than 4 cm dilated To stay at the hospital no matter how dilated I am To listen to music To have dimmed or natural lighting To wear my own clothes To wear hospital clothing To have my partner present the whole time To have the room quiet and peaceful as much as possible To wear my contacts or glasses To take pictures or video during birth To hydrate with liquids instead of an IV To have a heparine or saline lock To walk around and move freely To eat To have intermittent fetal monitoring To have continual fetal monitoring To keep my door closed To have as few vaginal exams as possible First Stage of Labor I would like to use these positions for pushing and birthing baby check all that apply Walk and move around, get into different positions Take a shower Sit on the birth ball Take a bath Lie down Pain Relief We are having a natural childbirth and will not need pain relief Please only provide pain relief if I ask for it If you see I am in pain, please suggest options to me I would like to try these methods for pain relief: Check all that apply Breath work Water (bath or shower) Sound therapy Movement Massage Visualization Meditation Distraction techniques Hot and Cold therapy Aromatherapy I would like to use or bring the following labor props: check all that apply Birth/peanut ball Squat bar (most hospitals have this) Tub Toilet Birthing stool Other (extra towels, sheets, etc) Second Stage of Labor I would like to use these positions for pushing and birthing my baby check all that apply Squatting Semi reclining Lying on my side Getting on all fours Kneeling lunge Birthing stool Standing Whatever feels right for me at the time Episiotomy I prefer not to have one and will risk tearing Please only perform an episiotomy To prevent tearing, I would like the following Check all that apply To have a hot compressed applied To have a perineal massage To have oil applied To breath through a slower crowning When it's time to push check all that apply I would like to do so instinctually, when I have the urge I want to be coached on how to push I want a combo of instinctual and coached pushing I want ot have unlimited time, as long as my baby and I are okay I want to use a mirror to see the birth of my baby I want to touch my baby's head as it crowns I want to avoid vacume extraction I prefer that my significant other catch the baby I would like to catch the baby and put him/her on my chest I prefer the room be silent as much as possible I prefer to use dim or natural lighting for the birth After Birth Once Baby is Born Check all that apply I want to hold my baby and have constant skin to skin I want to cut the cord and bank the cord blood I wish for the cord to remain attached until it stops pulsating I want my significant other to cut the cord I want to deliver the placenta spontaneously, without pitocin I want to save my placenta and take it home with me I want to breastfeed right away when the baby starts rooting If having a C-section My signifant other/doula is to be present at all times during the operation Please use a clear screen so I can see my baby being delivered I would like to remain conscious as much as possible Please discuss anesthesia options with me I would like the surgery explained while its happening I would like the birth to be photographed I would like my significant other to hold the baby and have skin-to-skin contact as soon as possible (if I am unable) In Recovery I want to breastfeed and have skin-to-skin contact right away If my baby needs additional medical attention, my significant other needs to be with my baby at all times Exams & Procedures (for baby) Hold off until we’ve had some time for bonding Perform exams and procedures with either me or my significant others presence My pediatrician will give (blank) to my baby Check all that apply Heel stick for screening test beyond the PKU test Hepatitis B vaccine Hearing test Vitamin K (shot or oral) Antibiotic eye ointment A bath Please don't bathe the baby and leave vernix on We decline all vaccines for our baby Feeding Check all that apply I plan on breastfeeding exclusively Please offer assistance for lactation support I plan to combine breastmilk and formula I plan to feed formula only Please only use this formula I brought with me Please don’t give my baby formula Please don’t give my baby sugar water Please don’t give my baby a pacifier If I have a boy, circuscision: Should not be performed Should be performed by Will be performed later Should only be done in the presence of me or my significant other Should be performed with anesthesia I would like my baby to stay in the room: 24 hours a day Unless I ask for the baby to go to the nursery Hospital Stay I would like to leave as soon as possible I would like to stay as soon as possible Special requests, questions, or notes for your significant other, Doctor, or Midwife Thank you!
