Basic information:

• Name: ______________
• My support person’s name: ______________
• Hospital/birthing center: ______________
• Due date/induction date: ______________
• Practitioner’s name: ______________

Before labor:

• My health factors include: ______________ I am on a blood thinner called Heparin. I also have asthma
• My planned delivery is: ______________ At the hospital
• My birth team includes: ______________ My Husband

During labor:

If medically possible, I would like to (circle all that apply):

• Eat and drink during labor if my practitioner allows it YES
• Be out of bed (walking around or sitting up) during labor YES
• Labor in water Maybe? If it helps I’ll try anything!
• Play music, dim lighting, use incense, scented candles Music, YES. Dim Lighting, YES. NO on incense and candles
• Have partner take photos or videos YES
• Labor with an exercise ball, in-room shower or birthing tub YES, if provided
• Use specific birthing positions NO, I will try any position that’s healthy for the baby
• Other:______________

Medical interventions:

I would prefer (circle all that apply, or make a note next to any you’d like to avoid):

• Artificial rupture of the membranes I would prefer to have anything rupture naturally
• Leave membranes intact for as long as possible YES
• External and internal electronic fetal monitoring NO
• Intermittent fetal monitoring NO
• Doppler fetal monitoring only YES
• The use of an IV or catheter or enema I tested positive for Strep B, which means I will have to take an IV with a prescription drip
• The use of oxytocin to induce or augment labor contractions NO
• Episiotomy GOD NO, PLEASE AT ALL COSTS NO
• Natural tearing only YES
• Vacuum extraction or forceps to assist in the birth NO
• Other:______________

Pain relief:

I would prefer (circle all that apply, or make a note next to any you’d like to avoid):

• Epidural NO
• Acupuncture YES, I have been doing acupuncture throughout this entire pregnancy
• Acupressure OMG yes please… do they have someone on staff at the hospital who would do this?
• Breathing exercises YES
• Massage YES, PLEASE
• Meditation YES
• Reflexology YES, PLEASE
• Other:______________

Delivery:

I would like to (circle all that apply):

• Use mirror to see baby crown YES, I think this would be so cool! 
• Have partner help catch baby Absolutely! My husband really wants to do this
• Allow partner to suction I don’t know what this means
• Allow partner to cut umbilical cord Yes, but only after the cord turns white

In case of a C-section:

If medically possible, I would prefer (circle all that apply, or make a note next to any you’d like to avoid):

• To be conscious YES
• Clear drapes be set up so I can watch as my baby emerges YES
• One arm to be left free of cuffs, monitors and IVs so I can hold the baby YES
• To breastfeed as soon as possible YES

Newborn care:

I would like to (circle all that apply, or make a note next to any you’d like to avoid):

• Hold the baby immediately after birth, allow baby time to creep from belly to breast YES
• Breastfeed immediately YES
• Have a lactation consultant help me breastfeed YES
• Bank the cord blood NO
• Donate the cord blood NO
• Keep the placenta to take home NO
• Give my baby formula NO
• Give my baby breast milk only YES
• Offer my baby a pacifier NO 
• Room-in with baby YES
• Let my baby sleep in the nursery YES, if I have been in labor for a long time and need to sleep
• Have circumcision performed if baby is a boy YES (but this has been the biggest fight between my husband and me)
• Give my baby vitamin K (I wish I didn’t have to give him this ‘vitamin’ but they wont circumcise without it)
• Give my baby antibiotic eye treatment NO
• Other:______________ NO HEP B VACCINE. ALL VACCINES TO BE DONE/DISCUSSED WITH HIS PEDIATRICIAN

What Happens If You Don’t Have a Birth Plan?

Some parents don’t have one and that’s ok! Whatever works for you to make you feel more comfortable when it’s “go time.” To some women, like me, it makes me feel prepared and in control of the moment. But to others it may make you feel anxious and overwhelmed. If you don’t feel comfortable speaking up and communicating your needs at the hospital, have your partner do it for you. Let them be your advocate!

Pregnant?