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.

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
Experience The Care You Deserve With A Birth Plan

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
pregnant woman

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
Experience The Care You Deserve With A Birth Plan

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
Experience The Care You Deserve With A Birth Plan

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