Back to Maternity Services Intro General Info Birth Philosophy Health Notes Before Labor Labor Induction During Labor Anesthesia Monitoring Preparation & Equipment 2nd Stage of Labor Episiotomy Delivery Cesarean Section 3rd Stage of Labor Postpartum Breastfeeding Circumcision My Hospital Stay Additional Notes Save/Print Monday, September 25, 2023 My Birth Plan We are looking forward to sharing your birth experience with you. We have created this birth plan in order to outline some of your preferences for birth. We would appreciate you reviewing this plan, and would be happy to do so with you. We understand that there may be situations in which your choices may not be possible, but we hope that you will help us to move toward your goals as much as possible and to make this labor and birth a great experience. We do not want to replace the medical personnel, but instead want to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Please feel free to ask if you have any questions or comments. Thank you! General Information First Name Last Name Phone Number Partner's Name Due Date or Induction Date Primary Care Doctor OB-GYN Coach/Doula/Labor Assistant Hospital/Birth Center/Location If home birth, name of hospital if complications ensue Birth Philosophy Birth Philosophy Health Notes Please note the following I am allergic to My blood type is I have Group B Strep I am Rh incompatible with the baby I have gestational diabetes My delivery is planned as Vaginal C-section Water birth VBAC Other Before Labor As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy. I would like to discuss laboring at home as long as possible. I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan. If NST observation becomes necessary after my due date, I am flexible and support this procedure. I prefer to have no vaginal exams until I go into labor. I prefer to have only one vaginal exam on or around my due date. I prefer minimal internal vaginal exams or at my request only. I would like no internal vaginal exams, within reason, during my labor until I have an urge to push. If I am less than four centimeters dilated, I would like to discuss with my healthcare provider the option of going home. Other Labor Induction/Augmentation As long as the baby and I are healthy, I would like to go at least 10 to 14 days over my due date before inducing labor. I would like to discuss the option of induction before I reach my due date. If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced. I would like the option of staying in the hospital regardless of my dilation and the discussion of induction. I’d also like labor induction/augmentation Performed only if baby is in distress Performed only when it is determined the mother or baby’s health would be improved by the birth of the baby First attempted by natural methods such as eating spicy foods, walking, herbs, nipple stimulation and sex Performed with Pitocin Performed with Cytotec Performed by stripping of the membrane Performed by rupture of the membrane Never to include an artificial rupture of the membrane (AROM) Other During Labor Upon arrival at the hospital, I prefer to have my partner with me at all times. Please, no residents or students attending my birth. Please always keep my door closed while I am in labor. I would prefer my water not be broken during labor. I would like encouragement throughout labor. Other These parties should have the following access I would like my Partner to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Parents to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Children to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Coach/Doula/Labor Assistant to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like Support Staff to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other During labor, I would also like To wear hospital clothing To wear my own clothes To wear contact lenses or glasses at all times when conscious To listen to music before birth To listen to music during birth The lights dimmed The room as quiet as possible As few interruptions as possible As few vaginal exams as possible To stay hydrated with clear liquids and ice chips To stay hydrated with IV and Heparin/saline lock To eat and drink as approved by my doctor I would like to be able to walk around, mobility is important to me. I would prefer a warm bath if I don’t feel up to walking. I would prefer to stay in one room during labor, birth, and post-delivery. My partner to film and/or take pictures Other During labor, I am not interested in Shaving of my pubic area A urinary catheter Other Anesthesia/Pain Medication For pain relief, I’d like to use Acupressure Breathing techniques Cold therapy Deep (or guided) relaxation Distraction techniques Hot therapy Hypnotherapy IV - Demerol IV - Nubain IV - Stadol Massage Meditation/Visual image work Narcotics Sedative Standard epidural Walking epidural Nothing I would like a natural birth if possible I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor. Please only offer pain medications if I ask for them. Please suggest pain management options for me if you see that I am too uncomfortable to handle the pain. Please discuss pain management options for me as soon as possible. After medical guidance for pain relief, I would appreciate some private time with my partner to discuss which pain management technique or medication I would like to use. Other Monitoring I’d like fetal monitoring to be Bradley techniques Childbirth hypnosis Continuous Intermittent Internal External Lamaze techniques Performed only by Doppler Performed only if the baby is in distress Other Preparation/Equipment I would like the following equipment available to me. If unavailable, I would like to bring them with me, if possible Birthing bed Birthing ball Birthing stool Beanbag Squatting bar Room with a shower Room with a pool/tub/bath Other 2nd Stage of Labor As long as the baby and I are healthy, I prefer to have no time limits on pushing. If pushing for more than several hours, I am open to medical intervention in 2nd stage labor. I would like counting to help me push. I would like a squat or birth bar to aid in pushing I prefer foot pedals to allow me to sit up while pushing I prefer stirrups to allow me to lay back during pushing I prefer my coach or doula to support my legs when pushing I would like to try to deliver in a hands-and-knees position I would like to try to deliver standing upright I would like to try to deliver lying on my side I would like to try to deliver in whatever way feels right at the time I wish to be able to move and change positions throughout my labor Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase I would appreciate guidance in when to push and when to stop pushing Please encourage me to breathe properly for slower crowning If possible, please allow the shoulders and body of my baby to be born spontaneously, on their own. Unless necessary for the safety of my baby, I do not want forceps or a vacuum extractor Other Episiotomy I would like an episiotomy Only if absolutely required for the baby's safety Used only after perineal massage, warm compresses and positioning Rather than risk a tear Not performed, even if it means risking a tear Performed only as a last resort Performed as my doctor deems necessary Performed with local anesthesia Performed by pressure, without local anesthesia Followed by local anesthesia for the repair Other Delivery 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 I would like to catch my baby and pull it onto my abdomen as it is born. I would like my partner to catch my baby. I would like the doctor to catch my baby. For spiritual or religious reasons, I would like the room to be totally silent as the baby is born. I would like for our baby to hear our voices first. As long as my baby is healthy, I would like my baby placed immediately skin-to-skin on my abdomen with a warm blanket over it. Other Cesarean Section Delivery If a C-section is necessary, I would like For my partner and I to be given time to think about it before we are asked for our written consent A second opinion To avoid a c-section if possible To make sure all other options have been exhausted To stay conscious The surgery explained as it happens An epidural for anesthesia For my partner to remain with me the entire time A low transverse incision on my abdomen and uterus The screen lowered so I can watch baby come out My hands left free so I can touch the baby after birth My partner to hold the baby as soon as possible To breastfeed my baby as soon as possible Other 3rd Stage of Labor Immediately after delivery, I would like To cut the cord myself For my partner to cut the cord My partner does not wish to cut the cord The umbilical cord to be cut only after it stops pulsating To bank the cord blood To donate the cord blood To deliver the placenta spontaneously and without assistance To keep the placenta To see the placenta before it is discarded To not see my placenta after birth I would like to hold the baby while I deliver the placenta and any tissue repairs are made I do not want an injection of Pitocin or Oxytocin after the delivery to aid in expelling the placenta Other Postpartum I would like to hold the baby Immediately after delivery After suctioning After weighing After being wiped clean and swaddled Before eye drops/ointment are given Other I’d like baby’s medical exam and procedures Given in my presence Given only after we’ve bonded Given in my partner’s presence To include a heel stick for screening tests beyond the PKU To include a hearing screening test To include a hepatitis B vaccine Placed on pulse oximetry after 24 hours of life to rule out any obvious heart conditions present at that time, as recommended by the federal government, American Academy of Pediatrics and American Heart Association. Other Please don’t give the baby Vitamin K Antibiotic eye treatment Sugar water Pacifier Other Whenever possible post-delivery, I would like To not be separated from my baby My partner to accompany the baby if the baby must be taken from me to receive medical treatment To have the baby's first bath and assessment done in my presence I prefer to hold the baby rather than have him or her placed under heat lamps Other As needed post-delivery, please give me Extra-strength acetaminophen Other pain medications as needed Stool softener Laxative Other If baby is not well, I’d like My partner and I to accompany it to the NICU or another facility To hold him or her whenever possible Other Breastfeeding I’d like to feed my baby Only with breastmilk Only with formula With breastmilk and formula On demand On schedule With the help of a lactation specialist Other I would like to breastfeed As soon as possible after delivery Before eye drops/ointment are given Later Never Other I would also like Any gift bags or diaper bags given to have formula removed Other Circumcision I do not want to have my baby circumcised I would like my baby circumcised in the hospital I would like to have my baby's circumcision done after discharge I would like anesthesia to be used during circumcision I would like to be present during circumcision Other My Hospital Stay For my hospital stay, I would like For my partner to stay in the room with me For the baby to room in with me For the baby to stay in the nursery at night so I can rest For my other children (regardless of age) to be allowed to visit with me for as long as they wish or as long as hospital policy permits For my guests to be permitted to stay as long as they wish Privacy during my stay and for my guests to limit the time they are visiting me To be discharged as soon as possible To stay as long as possible A private room, if available To have a TV in my room To have music in my room To use my own blanket and pillow To bring books and magazines to read Other Additional Notes Additional Notes Save My Birth Plan Save By selecting the Save button, your information will remain available for two days. If this is a public computer, we don't recommend saving this form. Print You may also print out your birth plan to have on hand during your pregnancy. Please consider the environment before printing. Reset By selecting the Reset button, your information will be cleared from all the above fields. Next Steps Once you complete your birth plan, we recommend the following next steps: Contact us to find out about tour options and maternity classes Print and discuss the birth plan with your doctor Bring a printed copy of the birth plan with you when you come to deliver at the hospital General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.) Congratulations! You've completed your birth plan! We recommend scheduling a tour next or making a doctor's appointment to talk through the plan for your big day. Schedule a tour Make an Appointment Ooops! An Unknown Error Has Occurred.
Monday, September 25, 2023 My Birth Plan We are looking forward to sharing your birth experience with you. We have created this birth plan in order to outline some of your preferences for birth. We would appreciate you reviewing this plan, and would be happy to do so with you. We understand that there may be situations in which your choices may not be possible, but we hope that you will help us to move toward your goals as much as possible and to make this labor and birth a great experience. We do not want to replace the medical personnel, but instead want to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Please feel free to ask if you have any questions or comments. Thank you! General Information First Name Last Name Phone Number Partner's Name Due Date or Induction Date Primary Care Doctor OB-GYN Coach/Doula/Labor Assistant Hospital/Birth Center/Location If home birth, name of hospital if complications ensue Birth Philosophy Birth Philosophy Health Notes Please note the following I am allergic to My blood type is I have Group B Strep I am Rh incompatible with the baby I have gestational diabetes My delivery is planned as Vaginal C-section Water birth VBAC Other Before Labor As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy. I would like to discuss laboring at home as long as possible. I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan. If NST observation becomes necessary after my due date, I am flexible and support this procedure. I prefer to have no vaginal exams until I go into labor. I prefer to have only one vaginal exam on or around my due date. I prefer minimal internal vaginal exams or at my request only. I would like no internal vaginal exams, within reason, during my labor until I have an urge to push. If I am less than four centimeters dilated, I would like to discuss with my healthcare provider the option of going home. Other Labor Induction/Augmentation As long as the baby and I are healthy, I would like to go at least 10 to 14 days over my due date before inducing labor. I would like to discuss the option of induction before I reach my due date. If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced. I would like the option of staying in the hospital regardless of my dilation and the discussion of induction. I’d also like labor induction/augmentation Performed only if baby is in distress Performed only when it is determined the mother or baby’s health would be improved by the birth of the baby First attempted by natural methods such as eating spicy foods, walking, herbs, nipple stimulation and sex Performed with Pitocin Performed with Cytotec Performed by stripping of the membrane Performed by rupture of the membrane Never to include an artificial rupture of the membrane (AROM) Other During Labor Upon arrival at the hospital, I prefer to have my partner with me at all times. Please, no residents or students attending my birth. Please always keep my door closed while I am in labor. I would prefer my water not be broken during labor. I would like encouragement throughout labor. Other These parties should have the following access I would like my Partner to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Parents to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Children to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like my Coach/Doula/Labor Assistant to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other I would like Support Staff to have access during 1st stage 1st and 2nd stages 1st, 2nd, and 3rd stages Recovery All 3 stages and recovery Other During labor, I would also like To wear hospital clothing To wear my own clothes To wear contact lenses or glasses at all times when conscious To listen to music before birth To listen to music during birth The lights dimmed The room as quiet as possible As few interruptions as possible As few vaginal exams as possible To stay hydrated with clear liquids and ice chips To stay hydrated with IV and Heparin/saline lock To eat and drink as approved by my doctor I would like to be able to walk around, mobility is important to me. I would prefer a warm bath if I don’t feel up to walking. I would prefer to stay in one room during labor, birth, and post-delivery. My partner to film and/or take pictures Other During labor, I am not interested in Shaving of my pubic area A urinary catheter Other Anesthesia/Pain Medication For pain relief, I’d like to use Acupressure Breathing techniques Cold therapy Deep (or guided) relaxation Distraction techniques Hot therapy Hypnotherapy IV - Demerol IV - Nubain IV - Stadol Massage Meditation/Visual image work Narcotics Sedative Standard epidural Walking epidural Nothing I would like a natural birth if possible I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor. Please only offer pain medications if I ask for them. Please suggest pain management options for me if you see that I am too uncomfortable to handle the pain. Please discuss pain management options for me as soon as possible. After medical guidance for pain relief, I would appreciate some private time with my partner to discuss which pain management technique or medication I would like to use. Other Monitoring I’d like fetal monitoring to be Bradley techniques Childbirth hypnosis Continuous Intermittent Internal External Lamaze techniques Performed only by Doppler Performed only if the baby is in distress Other Preparation/Equipment I would like the following equipment available to me. If unavailable, I would like to bring them with me, if possible Birthing bed Birthing ball Birthing stool Beanbag Squatting bar Room with a shower Room with a pool/tub/bath Other 2nd Stage of Labor As long as the baby and I are healthy, I prefer to have no time limits on pushing. If pushing for more than several hours, I am open to medical intervention in 2nd stage labor. I would like counting to help me push. I would like a squat or birth bar to aid in pushing I prefer foot pedals to allow me to sit up while pushing I prefer stirrups to allow me to lay back during pushing I prefer my coach or doula to support my legs when pushing I would like to try to deliver in a hands-and-knees position I would like to try to deliver standing upright I would like to try to deliver lying on my side I would like to try to deliver in whatever way feels right at the time I wish to be able to move and change positions throughout my labor Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase I would appreciate guidance in when to push and when to stop pushing Please encourage me to breathe properly for slower crowning If possible, please allow the shoulders and body of my baby to be born spontaneously, on their own. Unless necessary for the safety of my baby, I do not want forceps or a vacuum extractor Other Episiotomy I would like an episiotomy Only if absolutely required for the baby's safety Used only after perineal massage, warm compresses and positioning Rather than risk a tear Not performed, even if it means risking a tear Performed only as a last resort Performed as my doctor deems necessary Performed with local anesthesia Performed by pressure, without local anesthesia Followed by local anesthesia for the repair Other Delivery 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 I would like to catch my baby and pull it onto my abdomen as it is born. I would like my partner to catch my baby. I would like the doctor to catch my baby. For spiritual or religious reasons, I would like the room to be totally silent as the baby is born. I would like for our baby to hear our voices first. As long as my baby is healthy, I would like my baby placed immediately skin-to-skin on my abdomen with a warm blanket over it. Other Cesarean Section Delivery If a C-section is necessary, I would like For my partner and I to be given time to think about it before we are asked for our written consent A second opinion To avoid a c-section if possible To make sure all other options have been exhausted To stay conscious The surgery explained as it happens An epidural for anesthesia For my partner to remain with me the entire time A low transverse incision on my abdomen and uterus The screen lowered so I can watch baby come out My hands left free so I can touch the baby after birth My partner to hold the baby as soon as possible To breastfeed my baby as soon as possible Other 3rd Stage of Labor Immediately after delivery, I would like To cut the cord myself For my partner to cut the cord My partner does not wish to cut the cord The umbilical cord to be cut only after it stops pulsating To bank the cord blood To donate the cord blood To deliver the placenta spontaneously and without assistance To keep the placenta To see the placenta before it is discarded To not see my placenta after birth I would like to hold the baby while I deliver the placenta and any tissue repairs are made I do not want an injection of Pitocin or Oxytocin after the delivery to aid in expelling the placenta Other Postpartum I would like to hold the baby Immediately after delivery After suctioning After weighing After being wiped clean and swaddled Before eye drops/ointment are given Other I’d like baby’s medical exam and procedures Given in my presence Given only after we’ve bonded Given in my partner’s presence To include a heel stick for screening tests beyond the PKU To include a hearing screening test To include a hepatitis B vaccine Placed on pulse oximetry after 24 hours of life to rule out any obvious heart conditions present at that time, as recommended by the federal government, American Academy of Pediatrics and American Heart Association. Other Please don’t give the baby Vitamin K Antibiotic eye treatment Sugar water Pacifier Other Whenever possible post-delivery, I would like To not be separated from my baby My partner to accompany the baby if the baby must be taken from me to receive medical treatment To have the baby's first bath and assessment done in my presence I prefer to hold the baby rather than have him or her placed under heat lamps Other As needed post-delivery, please give me Extra-strength acetaminophen Other pain medications as needed Stool softener Laxative Other If baby is not well, I’d like My partner and I to accompany it to the NICU or another facility To hold him or her whenever possible Other Breastfeeding I’d like to feed my baby Only with breastmilk Only with formula With breastmilk and formula On demand On schedule With the help of a lactation specialist Other I would like to breastfeed As soon as possible after delivery Before eye drops/ointment are given Later Never Other I would also like Any gift bags or diaper bags given to have formula removed Other Circumcision I do not want to have my baby circumcised I would like my baby circumcised in the hospital I would like to have my baby's circumcision done after discharge I would like anesthesia to be used during circumcision I would like to be present during circumcision Other My Hospital Stay For my hospital stay, I would like For my partner to stay in the room with me For the baby to room in with me For the baby to stay in the nursery at night so I can rest For my other children (regardless of age) to be allowed to visit with me for as long as they wish or as long as hospital policy permits For my guests to be permitted to stay as long as they wish Privacy during my stay and for my guests to limit the time they are visiting me To be discharged as soon as possible To stay as long as possible A private room, if available To have a TV in my room To have music in my room To use my own blanket and pillow To bring books and magazines to read Other Additional Notes Additional Notes Save My Birth Plan Save By selecting the Save button, your information will remain available for two days. If this is a public computer, we don't recommend saving this form. Print You may also print out your birth plan to have on hand during your pregnancy. Please consider the environment before printing. Reset By selecting the Reset button, your information will be cleared from all the above fields. Next Steps Once you complete your birth plan, we recommend the following next steps: Contact us to find out about tour options and maternity classes Print and discuss the birth plan with your doctor Bring a printed copy of the birth plan with you when you come to deliver at the hospital General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.) Congratulations! You've completed your birth plan! We recommend scheduling a tour next or making a doctor's appointment to talk through the plan for your big day. Schedule a tour Make an Appointment Ooops! An Unknown Error Has Occurred.