Birth Plan for (Your Name): ______________________________________________________________________________
My baby’s father’s name is: ___________________________________________________________________________
My other support person wil be: ______________________________________________________________________
You may write your own birth philosophy, whatever you want. Here is an example you can revise as needed or leave out entirely.
This birth plan is intended to express the preferences and desires we have for the birth of our baby. It is not intended to be a script. We ful y realize that situations may arise such that our plan cannot and should not be fol owed. However, we hope that barring any extenuating circumstances, you wil be able to keep us informed. Thank you. First Stage of Labor Environment
______ I would prefer dim lights and quiet atmosphere ______ I would like to play my own music ______ I would prefer no students please ______ Students are welcome unless otherwise stated
Pain Relief
______ I would prefer to use non-medical pain relief methods unless I state otherwise (relaxation,
positioning, tub, heat or cold therapy, birthing bal , massage)
______ I would like pain meds offered as soon as possible (Stadol, Demerol/Phenergan, epidural)
Second Stage
_____ I would like to try various positions during pushing (to al ow the baby to rotate and move
_____ I would like to try the birthing stool with pushing (a stool that sits on the floor and offers a
passive squatting position and the use of gravity to aid in the descent of the head)
Perineal Care
_____ I would prefer no Episiotomy if possible (through the use of massage, positioning and
Cutting the Cord
I wish ___________________________ to cut the cord ________________________does not wish to cut cord
Feeding the Baby
_____ I plan to breast feed and would prefer no pacifiers or artificial nipples unless medical y
_____ I plan to breast feed with supplement (not recommended for the first 2-3 weeks after
_____ I plan to bottle feed only and my formula of preference is _____________________________________ _____ No pacifiers please
_____ I would like my baby placed on my abdomen at birth _____ I would prefer my infant dried and wrapped before given to me _____ I would prefer my baby to stay with me as much as possible during the first hour after birth
_____ I would like my baby to room-in (stay in the room at al times unless needed for assessments,
_____ I would prefer rooming-in except at night when I would like my baby brought in for feedings
Circumcision
_____ I plan to have my baby circumcised _____ I do not wish to have my baby circumcised
Complications and Cesarean Surgery
_____ I would prefer spinal anesthesia for non-emergent cesarean birth (stay away and have
_____ I would prefer general anesthesia (go to sleep and not have support person present) _____ I would like to take pictures (with permission of the attending physician)
Sick Infant
_____ If my baby is unable to leave the nursery I would like to express milk for feedings and breast
_____ If my baby were transferred to another facility I would like to be discharged as soon as
Al of these are areas to consider and discuss with your providers at your regular checkups or with your childbirth educator, then create your birth plan with your own preferences.
MAKE 3 COPIES One to give to your provider at your office visit for your chart One to bring with you to the labor room when you come in One to keep for yourself Our staff is here to help you have a satisfying and healthy birth experience.
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Birth Plan for (Your Name): ______________________________________________________________________________
My baby’s father’s name is: ___________________________________________________________________________
My other support person wil be: ______________________________________________________________________
You may write your own birth philosophy, whatever you want. Here is an example you can revise as needed or leave out entirely.
This birth plan is intended to express the preferences and desires we have for the birth of our baby. It is not intended to be a script. We ful y realize that situations may arise such that our plan cannot and should not be fol owed. However, we hope that barring any extenuating circumstances, you wil be able to keep us informed. Thank you.