Interactive Birth Plan

* Your name: Your spouse's name: Title of birth plan: Your birth plan will be titled "My Birth Plan" unless you erase the contents or edit it with your own title.
Your due date: (MM/DD/YY)
Name of your doctor or midwife:
Birth assistant name: If you have one and want her/him included
Place of birth: This birth plan is prepared for:

Normal (vaginal) delivery
Cesarean
Induction
Twins or multiple birth
VBAC (vaginal birth after Cesarean)
Other (please type)

Statement:

This statement will appear on your birth plan unless you erase the contents or edit it with your own words.

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Site Essentials

Make Your Birthing Wish List

Private birthing room

Dim lights

Peace and quiet

Bring our own music

Wear my own clothes

Private phone

We would like to video labor and birth

We would like to take pictures during labor and birth

No unnecessary exams or visits by students, residents, etc.

Minimal vaginal exams (vaginal exams can actually cause problems such as infection and premature rupture of membranes)

Other (Please Specify)

Free to walk around and go to the bathroom throughout labor

Freedom to move in bed only (and to use the bathroom)

Mobility not important (catheter, regular epidural)

I would prefer to avoid an enema and/or shaving of pubic hair

I would like to be able to eat and drink whatever I want

I would like to be free to drink clear fluids

I would like ice chips available to me at all times

Heparin/Saline lock (Most hospitals require this as access to a vein should an emergency occur, it can also be used in place of an IV for administration of antibiotics for complications such as MVP or Beta Strep)

I do not want an IV unless I become dehydrated

I would like to choose my positions for pushing and giving birth

I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby

I do not want an internal monitor unless the baby has shown some sign of distress

I prefer fetal monitoring

I plan to give birth naturally without medication and will be coping with pain using the following techniques

I am attempting a natural childbirth but if I ask for pain medication I'd like to use

Please administer pain medication as soon as possible

Bradley Method

Lamaze

Water (shower or tub)

The Alexander Technique

Massage

Acupressure

Other, please state:

Stadol

Walking epidural (low dose)

Epidural block

Other

do not wish to have the amniotic membrane ruptured artificially unless their are signs of fetal distress

If labor is not progressing, I would like to have the amniotic membrane ruptured before other methods are used to augment labor

I would prefer to be allowed to try changing position and other natural methods before medical methods or medications are used

Unless absolutely necessary, I would like to avoid a Cesarean

If my primary caregiver recommends a Cesarean birth, I would like a second opinion if time warrants

If my primary physician recommends a Cesarean, I accept and will cooperate with the procedure at any time

I would like a mirror available so I can see the baby's head when it crowns

I would like to have the baby placed on my stomach/chest immediately after delivery

I would like to try to deliver in a hands-and-knees position

Please dim the lights for the birth

I would appreciate having the room as quiet as possible when the baby is born

I want an injection of Pitocin after the delivery to aid in expelling the placenta

I would like to see the placenta after it is delivered

Prefer no episiotomy (massage, compresses, positioning, etc.) Select this one if you would prefer no episiotomy but not to the point of tearing.

Prefer to tear (massage, compresses, positioning, etc.) Select this option if you would prefer to tear rather than have an episiotomy.

Episiotomy

Pressure episiotomy (Done without anesthesia, although you cannot feel it due to the pressure from the baby's head.)

Local anesthesia (for repair)

If you're scheduled for a Cesarean birth or if it becomes medically necessary for the health of you or your baby, please state your preferences.

Spinal/epidural anesthesia

General anesthesia

I would like my partner or coach present

I would like my partner to be able to take video/pictures

Screen lowered to view birth

Touch the baby as soon as possible

Partner to cut cord

Other (Please specify):

Partner would like to cut cord

I would like to cut the cord

Neither of us wishes to cut the cord

None

Delayed for bonding time

Immediate

Breastfeeding only

Bottle feeding only

Combination

No pacifiers or glucose water (To avoid nipple confusion.)

No separation: baby/mother rooming in

Delayed (after recovery period)