Birth Plan
Name of Doula
First Name
Last Name
Name of Mother
First Name
Last Name
Birth Center
Est Due Date
-
Month
-
Day
Year
Date
Who I Want in the Room
Partner
Parent
Doula
Midwife
Children
Other
Medical Preferences
No Induction unless medically necessary
Artificial Induction with Pitocin
Membrane Sweep/Stripping
Natural Induction (castor oil, herbs, aromatherapy, orgasmic, etc.)
Membrane Rupture only if necessary
Standard Epidural
Walking Epidural
Gas/O2
Natural childbirth with no Epidural or pain meds
Demoral or other drugs
Other
Environmental Preference
Music
Chatter
Silence
Calm atmosphere
Soft lighting
Meditation
Other
Monitoring/Exams
Electronic/Internal Fetal Monitoring
Doppler Fetal Monitoring
Intermittent monitoring
Vaginal Exams Okay
Limited Vaginal Exams
No Vaginal Exam
Vaginal Exam by Doctor only
Other
Personal Preferences
Few Interruptions
My own staff (doctors/nurses/midwives only, no students, residents or interns)
Wear my own clothes
Wear my contact lenses instead of glasses
Photos and Videos by my partner/doula
Laboring Preferences
Eating/Drinking
Breathing Techniques
Mobility (Laboring out of bed)
Body Massage
Water Pool
Shower
Aromatherapy
Heat pack
Cold pack
TENS unit
Rebozo
Distraction Therapy
Accupressure/Accupuncture
Laboring No-NOs
No enema
No shaving pubic area
No urinary catheter
No IV unless dehydrated
Delivery Position Preference
Squat
Semi-Recline
On left side
Hands and knees
Standing
Lean on Partner
Birth Bar
Birth Stool
Birth Tub
Birth Shower
Episiotomy Preferences
Only after perineal message or warm compresses
Only to avoid a tear
Not performed, even if it means risking a tear
Only with local anesthesia
Only as last resort or harm to baby
Let wear off while pushing
Have a full dose during entire labor
Delivery Preference
Push spontaneously
Push as directed
Push without time limits
Use a mirror to see baby crown
Touch head as it crowns
Avoid forceps
Avoid vacuum
Have partner catch the baby
Let partner suction baby
C-section Preferences
Require 2nd opinion
Make sure all other options have been exhausted
Stay conscious
Partner to remain with me the entire time
Doula present in the room
Screen lowered to watch baby come out
Hands-free to touch the baby
Surgery explained as it happens
Partner to hold baby to me as soon as possible
Breastfeed in the recovery room
Post Delivery Preferences
Partner to cut umbilical cord
Umbilical cord cut ONLY after it stops pulsating
Bank the cord blood
Donate the cord blood
Deliver placenta spontaneously without assistance or medication
Placenta to be kept on ice for encapsulation
Do not remove vernix while in the hospital
Do not bathe baby while in the hospital
Baby Holding Preferences
Immediately after delivery
After suctioning
After weighing
Before eye drops given
After lightly wiped and swaddled
Bonding/Skin to skin contact on me
Bonding/Skin to skin contact with my partner
Breastfeeding Preferences
As soon as possible after delivery
Later
Never
Family Preferences
Join me and baby immediately after delivery
Join me and baby later
Only to see baby in nursery
To have unlimited vising after birth
Family members listed below PROHIBITED
Other
Baby Exams and Procedures
Given in my presence
Given only after bonding
Given in my partner's presence
Include heel stick for PKU testing
Include hearing test
Include Hepatitis B Vaccine
Include Vitamin K shot
Include Antibiotic eye treatment
Use Sugar Water
Use formula
Use a pacifier
Baby Feeding Preferences
Only breastmilk
Only formula
On demand
On schedule
With help of Lactation Specialist
Baby Bathing Preferences
In my presence
In my partner's presence
By me
By my partner
Rooming Preferences
Partner to sleep in my room
Baby to stay in my room all of the time
Baby to stay in my room only when I'm awake
Baby in room only for feedings
Baby in room only upon request
Partner to have unlimited visitation
Doula to have unlimited visitation
Circumcision Preferences
Do perform
Do NOT perform
Perform later
Performed with anesthesia
Performed in presence of me and/or my partner
Post-Delivery Pain Relief Preferences
Extra-strength acetaminophen
Percocet
Stool Softener
Laxative
Other
Emergency Baby Preferences
My partner and/or I to accompany baby to NICU or other facility
To breastfeed or provide pumped breastmilk during baby's stay
To hold baby whenever possible
Other
Hospital Stay Preferences
24hr release
48hr release
Stay as long as possible
In an emergency, if I am unable to speak for myself, I would like the following person to be my advocate.
My Partner
My Doula
My Midwife
Other
Concerns that I Have
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