Create a Birth Plan

Saturday, June 3, 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

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

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

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

Postpartum

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

Additional Notes

Save My Birth Plan

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.

You may also print out your birth plan to have on hand during your pregnancy. Please consider the environment before printing.

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.)

Create a Birth Plan

My Birth Plan

General Information

Birth Philosophy

Health Notes

Before Labor

Labor Induction/Augmentation

During Labor

Anesthesia/Pain Medication

Monitoring

Preparation/Equipment

2nd Stage of Labor

Episiotomy

Delivery

Cesarean Section Delivery

3rd Stage of Labor

Postpartum

Breastfeeding

Circumcision

My Hospital Stay

Additional Notes

Save My Birth Plan

Next Steps

Once you complete your birth plan, we recommend the following next steps: