Experience The Care You Deserve With A Birth Plan -

Do you already have a birth plan laid out? Make sure that your medical team is equipped with all the information about your needs by filling this simple worksheet.

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Experience The Care You Deserve With A Birth Plan

Your Name: ________ Partner’s Name: ________

Due Date: _______ Doctor/Midwife’s name: ________

Name of the Hospital: ________ Address of the Hospital: ________

I am going to have ______

Vaginal Delivery
C-Section Delivery
Water Birth
Vaginal Birth after Cesarean

Before and during birth, I’d like to have my _____ around

Partner
Parents
Other Children
Siblings
Birth attendant
Other

I want you to keep a note of the fact that I

Have group B strep
Have gestational diabetes
Rh incompatibility

For a Comfortable Environment during Labour

I’d like to:

Have my partner around at all times
Have soothing music play in the background
Dim the lights
Have a quiet setting
Have minimal interruptions
Have minimal vaginal examinations
Have only my practitioner and nurse around without any interns or students
Wear my own clothing
Bring my own blankets and pillows
Wear contact lens throughout the birth
Have videos and pictures taken by my partner or ______
Essential oils or aromatherapy scents
Follow the diet instructed by my doctor
Stay hydrated

In my first stage of labor, I want to cope by _____

Walking or moving around
Having a warm bath or shower
Staying in an upright or standing position
Lying down

I want the fetal monitoring to be ____

Internal
External
Continuous
Intermittent
Using a fetal Doppler
Dependent on baby’s condition and if it is in distress

I would want to opt for labor augmentation if ______

It concerns my baby
When natural methods like nipple stimulation have been ineffective
Prostaglandin gel will be used
Labour can be induced by stripping the membrane
Pitocin will be used
Labour can be induced by rupture of the membrane
Artificial rupture of the membrane is excluded

I do not want to ______

Have my pubic area shaved
An enema
A drip (which should be used only if I am dehydrated)
A catheter

For pain management, I would like to opt for

Pain medication but only if I request it at that time
Meditation
Relaxation
Acupuncture
Acupressure
Breathing exercises
Changing position or walking around
Fitness ball
Hot or cold therapy
A relaxing massage
TENS
Soothing music
Distraction
Epidural
Analgesia
What I request for at that time
Other

I will bring ____ along with me

Birthing chair or stool
Birthing ball
Birthing tub

To ease me during delivery, I would like to ______

Try different positions
Squat
Take the support of my partner
Position me on my hands and knees
Stand
Lie on one side
Employ foot pedals
Use squat bar
Use people for leg support
Use birth bar
Use a birthing tub
Be in the shower

During the delivery of the baby, I would like to _____

Push instinctively, as long as baby and I are not at risk
Be coached about when and how to push
Have my partner catch the baby
Have my partner assist in suctioning the baby
Use a mirror to view the birth or crowning
Touch the head of my baby during the crowning
Opt for epidural
Let the effects of epidural wear off during labor
Avoid the use of forceps
Avoid the use of vacuum extraction
Let the doctors resort to their own methods for the safety of the baby

If I am having a C-section, I would like to _____

Make sure that it has opted only as of the last resort
Think about it and get a second opinion
Stay conscious throughout the delivery
Have my partner around throughout the operation
View the birth of my baby
Have my arms free so that I can have skin-to-skin contact with my baby
Be explained every step of the surgery as it is conducted
Opt for epidural
Have my partner be handed the baby soon after the surgery
Breastfeed in the recovery room

I will opt for an episiotomy ______

If it is carried out after perineal massage and warm compress
Rather than increasing the chance of a tear
If the doctor is out of options
If the doctor considers it to be necessary
With the help of local anesthesia
If the doctor uses pressure and avoids the use of local anesthesia
I Will not opt for an episiotomy but would rather risk a tear

Post-delivery I would like _____

To Cut the umbilical cord
Have my partner cut the cord
The pulsating stop before the umbilical cord is cut
To donate the cord to a public bank
To store the cord blood
To deliver the placenta without any assistance
To have a look at my placenta before it is disposed
Avoid Pitocin or oxytocin

I would prefer to hold my baby _____

Soon after the delivery
Post suctioning
After it is given the eye drops and ointment
Post weighing
Once it is wiped clean

I would like to opt for breastfeeding

Soonest post-delivery
Later
After the baby is given eye drops
Never and exclusively formula feed

I would prefer if my family members

Visit the baby and me immediately post-delivery
Only visit the baby in the nursery
Visit the baby and me in the recovery room later
Are given ample time to visit after the birth

I would want all the medical procedures for my baby to be ________

Conducted in my presence and/or my partner’s presence
Given once we have bonded
To consist of vaccines
To consist of newborn hearing screening test
To consist of a heel stick test

I request you to avoid giving _____ to the baby

A pacifier
Formula
Vitamin K
Antibiotics

For feeding my baby, I would prefer _____

only breastmilk
formula
to follow a schedule
to pay attention to the baby’s demand
to consult a lactation specialist

My baby should preferably stay in the room ______

Upon my request
All the time
Daytime
When I am awake
Only when it needs to be fed

For baby’s bath, I would prefer ____

To do it myself
My partner to do it
It to be done in my presence
It to be done in my partner’s presence

I will prefer if my partner _____

As unlimited visiting hours
Stays/sleep in my room the entire time

Concerning circumcision, I would prefer if my baby boy _____

Is circumcised
Is not circumcised
Is circumcised later
Undergoes circumcision under anesthesia
Is circumcised in my or my partner’s presence

Post-delivery, I might need _____ as per requirements

Stool softener
Laxative
Percoset

If my baby is not feeling well, I would prefer ____

To hold it for as long as possible to comfort it
To provide it with breastmilk, either by feeding or breast pump
My partner and accompany it to another facility

Post-delivery, my stay in the hospital should be for a _____

Brief period
Long-period

Do you find this article about having a birth plan helpful? Do you want to read more relevant articles? Check out this list!

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7 Signs Childbirth Will Be Hard For You.

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Liliana

Liliana is a Licensed Montessori teacher known for her passion and dedication to education. She's been a teacher in the United States for many years, and she truly believes that education is the key to making the world a better place because today's students are tomorrow's leaders. Her experience with Toddlers, Beginners, VPK with Montessori methodology approach; Kindergarten, and first grade made her an authority and trusted resource. Liliana's family taught her important qualities like love, a positive attitude, strong motivation, and leadership. These values have guided her on her journey to becoming a professional and expert teacher. Her mission is to help children grow and contribute to a brighter future for the country.