Please take your time when filling out this form. You don't need to finish it at once, you can take weeks to complete it. It would be great to discuss your preferences with
your OB or midwife so that you can decide which options are best for you and your baby.

First Name Last Name

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First Name Last Name

Hospital admission forms Cord blood/placenta banking materials and instructions Insurance forms Other

To view the birth using a mirror To touch my baby’s head as it crowns The hospital staff to help me with pushing techniques To be able to feel the urge before starting to push

To move around freely during labor To change positions frequently To have access to labor in the shower/ birth tub To have the lights dim To listen to music of my choosing To have access to the following labor props (see other) Other

If your doctor or midwife believes induction is necessary, you would prefer the following:

Dinoprostone cervical ripening vaginal insert, FDA-approved Dinoprostone cervical ripening gel, FDA-approved Pill (Cytotec®/misoprostol), not FDA-approved for cervical ripening Balloon Catheter, some are FDA-approved Other

If I need any of these procedures, please discuss with me beforehand. I would prefer not to have an episiotomy unless medically necessary. I would prefer not to have forceps used. I would prefer not to have a vacuum used. Other

Walking around My doctor or midwife will break my water Nipple stimulation Other

If possible, I’d like to have a moment alone or with my partner/family/other prior to the procedure. I’d like to have a support person present for the procedure. I’d like a sheer screen to watch, if possible. I’d like to have the procedure explained as it happens. I’d like to have music playing. If possible, I’d like to have immediate skin-to-skin contact with my baby. Other

Immediately after delivery (skin-to-skin) After being wiped clean After being weighed and cleaned Other

My partner or support person will cut the cord. I prefer delayed clamping or cutting of the cord. I want to take my placenta home. Cord collected for banking Placenta collected for banking Blood collected for banking

I want my baby circumcised prior to leaving the hospital. I do not want my baby circumcised prior to leaving the hospital.

Breast milk (I prefer my baby not receive bottles at this time.) Breast milk (My baby may receive a bottle of breast milk if needed.) Formula Other

As soon as possible after delivery When I feel comfortable I would like to see a lactation consultant in the hospital, if possible Other

Birth Plan Form