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.

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

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

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

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

Do you find this article about having a birth plan helpful? Do you want to read more relevant articles? Check out this list!

• Hospital Bag Checklist: What to Take to the Maternity Hospital?

• Labor Companion: Do You Need It? How Can a Man be Helpful During the Labor?

• 7 Signs Childbirth Will Be Hard For You.

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