Birth Plan Form

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.

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Hospital admission formsCord blood/placenta banking materials and instructionsInsurance formsOther

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

To move around freely during laborTo change positions frequentlyTo have access to labor in the shower/ birth tubTo have the lights dimTo listen to music of my choosingTo 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-approvedDinoprostone cervical ripening gel, FDA-approvedPill (Cytotec/misoprostol), not FDA-approved for cervical ripeningBalloon Catheter, some are FDA-approvedOther

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 aroundMy doctor or midwife will break my waterNipple stimulationOther

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-skincontact with my baby.Other

Immediately after delivery (skin-to-skin)After being wiped cleanAfter being weighed and cleanedOther

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 bankingPlacenta collected for bankingBlood 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.)FormulaOther

As soon as possible after deliveryWhen I feel comfortableI would like to see a lactation consultant in the hospital, if possibleOther