Title for your plan:

Birth Plan   Birth Preferences   Our wishes for Childbirth   My wishes for Childbirth

Regarding Labor and Birth

First name:

Middle name:

Last name:

Name of primary healthcare provider:

Name of Hospital/Center where you plan to deliver:

Your due date:

Coach (you might want to just write ‘my husband,’ or ‘my coach’):

Your other support staff

How would you like to refer to your baby? (My baby, the babies, my son, etc.)

Labor

I will be bringing my own music to play during labor.

I would like the environment to be kept as quiet as possible.

I would like the lights in the room to be kept low during my labor.

I would like to wear contact lenses or glasses at all times.

Other:

Labor Augmentation/Induction

I do not wish to have the amniotic membrane ruptured artificially unless absolutely necessary.

If labor is not progressing, I would like to have the amniotic membrane ruptured before other methods are used to augment labor.

I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation) before the amniotic membranes are ruptured.

Other:

Anesthesia/Pain Medication

I am interested in using nitrous oxide during transition if necessary.

I am interested in lidocaine injected into the perineum just prior to crowning to reduce burning.

I am interested in sterile water papules if I have back labor.

I am interested in TENS units or acupuncture during labor.

I am interested in using the SaniJet tub as my “aquadural” during transition.

Other:

Episiotomy

I would prefer not to have an episiotomy unless absolutely required for the baby’s safety.

I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.

I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch.

If possible, I would like to use perineal massage to help avoid the need for an episiotomy.

Other:

Delivery

I would like to be allowed to choose the position in which I give birth, including squatting.

I would like (partner) and/or nurses to support me and my legs as necessary during the pushing stage.

I would like to try to deliver in a hands-and-knees position.

I would like to try to deliver in a squatting position, using (coach) or ballet bar for support.

I would like a mirror available so I can see the baby’s head when it crowns.

I would like the chance to touch the baby’s head when it crowns.

Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.

I would appreciate having the room lights turned low for the actual delivery.

I would appreciate having the room as quiet as possible when the baby is born.

I would like to have the baby placed on my stomach/chest immediately after delivery.

Other:

Immediately After Delivery

I would like to have (coach) cut the cord.

I would like (other) to cut the cord.

I would like to cut the cord myself.

(coach) does not wish to cut the cord.

I would prefer that the umbilical cord stop pulsating before it is cut.

I would like to hold the baby while I deliver the placenta and any tissue repairs are made.

I would like to delay/decline the eye medication for the baby until a couple hours after birth.

I would like to donate the umbilical cord blood if possible.

I would like to bank the umbilical cord blood, and have made arrangements to do so.

I would like to see the placenta after it is delivered.

I would like to take my placenta home upon discharge.

Other:

Breastfeeding

I plan to breastfeed the baby and would like to begin nursing very shortly after birth.

I do not plan to breastfeed the baby.

I would like to meet with a Lactation Consultant.

Other:

Circumcision

I do not want the baby circumcised

I would like the baby to be circumcised.

Other:

Photo/Video

I would like to take still photographs during labor and the birth.

I would like to make a videorecording of labor and/or the birth.

Other:

Other

My support people are (support people) and I would like them to be present during labor and/or delivery.

I would like my other child/ren to be able to visit me and the baby in the hospital.

I would prefer that no students, interns, residents or non-essential personnel be present during my labor or the birth.

Other: