My Birth Plan Template.

Please feel free to use! Nothing is more important to have your wishes laid out before you enter the hospital or give birth, but also knowing that your wishes might change once you get there :) Contact me if you would like to know more about birth plans, etc.
Birth Plan for the ___________________ family.
Mother's first and last name:
Father's first and last name:
Due Date:
Coach's first and last name:
Other support people:
Name of obstetrician:
Desired hospital:
Early/First Stage Labor
Environment
__Low lighting
__Quiet room
__Music
__Wear own clothing
__Coach/partner only desired attendees other than medical staff
__I would prefer to wear my contact lenses/glasses
__I want my labor and delivery photographed/video recorded
__I do not want my labor and delivery photographed/video recordedOther
Mobility Choose one.
__Unlimited freedom to move (walking, bathroom, rocking chair, fitness ball, etc.)
__Mobility is not important to me
Shaving/Enema Most hospitals no longer shave the pubic area or use enemas, but just in case. __I would like to avoid the use of an enema.
__I would like to avoid having my pubic area shaved.
I.V.
__ I.V. insertion is acceptable at any point
__ I.V. placement should be attempted only if dehydration occurs
__ Please attempt to insert I.V. on left/right (circle)
Hydration
__ No restrictions
__ Clear fluids
__ Ice chips
__ IV
Monitoring Choose one.
__Intermittent monitoring (Fetoscope, Doppler, etc.)
__Continuous monitoring (External leads, internal monitoring)
__No monitoring except in emergency situations
Catheritization
__I would like to avoid catheterization unless it is absolutely necessary
Pain Relief Offer Choose one.
__Do not offer; I will ask if I desire it
__Offer if I appear uncomfortable
__Offer as soon as possible
Pain Relief Options
__Natural Relaxation techniques
__Hot or cold compresses
__Positioning
__Water therapy (bath, whirlpool, shower)
__Massage
__Accupressure
__Hypnotherapy
I.V. Medication
__Stadol
__Nubain
__Demerol
Other ________________
Epidural
__Walking epidural
__Traditional epidural
Labor Induction/Augmentation
__No induction
__No augmentation
__Cervical gel
__Pitocin
__Rupturing of the amniotic sac
__I prefer my amniotic sac be allowed to rupture on its own
Second Stage Labor
Pushing Check all pushing options which are acceptable.
__Push in position of my choosing
__Squat/Birthing Bar
__Pushing while on hands and knees
__I am not concerned with positioning
__Foot pedals rather than stirrups
__People as leg support rather than stirrups
__Spontaneous pushing (when I feel the need)
__Pushing with medical direction
Delivery
__I would like to touch baby's head when it crowns
__I would like a mirror available to view pushing/crowning/birth
Immediately following delivery
__I want baby placed on my chest immediately after birth
__I would like to breastfeed as soon as my baby is delivered, before he is cleaned off
__I would like my partner/coach to cut the cord
__I would like to cut the cord
__Partner/coach does not want to cut cord
__Please delay cord clamping and cutting until pulsating ceases
__I would like to hold the baby while delivery placenta
__I do not wish a pitocin injection to assist with placenta delivery
__I wish baby to be examined in my presence.
__If baby cannot be examined in my presence, I wish my partner/coach to remain with baby at all times
__I do not wish baby to be placed under heat lamps; I will hold baby and provide body warmth instead
__I want to donate cord blood
__I want to bank cord blood
Episiotomy
__I do not want an episiotomy unless there is an emergency situation
__I would like to attempt perineal massage to stretch the perineum.
__I would like an episiotomy to reduce risk of tearing
__I would like a local anesthetic during repair of tear/episiotomy
__I would not like a local anesthetic during repair of tear/episiotomy
Baby Care
__I wish to breastfeed exclusively
__I wish to breastfeed, but formula supplementation is acceptable
__I wish to formula feed
__I do not want baby to be given a pacifier
__I would like to meet with a lactation consultant as soon as possible
__I want baby circumcised
__I do not want baby circumcised
Privacy
__I would like a private room, I understand that there will be an additional charge
__I would like baby to "room in"
__I would like baby to sleep in nursery
__I would like baby to be brought to me for all feedings
__I welcome all well wishers
__I wish to limit visitors
__I would prefer my door closed with a sign requesting that visitors and staff members knock before entering
__I do not wish to have medical students involved in my care
__Other _____________________
Cesarean
In the event that a cesarean section is deemed necessary, I would like the following:
__Partner/coach present
__Other support present ________________
__Pictures/video
__Screen lowered at delivery
__I would like the procedure described as it is happening
__Partner would like to cut cord
__Other ___________________
In the event that baby requires special care due to trauma or illness
__I would like to breastfeed/pump breast milk
__Partner/coach will accompany baby if transferred to another hospital
__I would like to be transferred to baby's hospital

Mother's Signature __________________________ Date ______
Father's Signature __________________________ Date ______