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
______ 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.

Source: http://www.oswegohealth.org/maternity-center/Birth%20Plan%20Final.pdf


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