(For a printable version click here)

Date:

I _______________________________ am creating this birth plan prior to my labor in order to make my wishes clear to my doctor/midwife, and the nurses at the hospital where I am delivering. These are the items I consider important in the birth of my unborn baby and I would like them to be followed as closely as possible whenever able. I understand that a circumstance might come up where either I may change my mind or that my doctor/midwife may feels that it is in my best interest to deviate from my birth plan. I will be flexible, although I ask to be kept informed ahead of time of every aspect of my labor.

My name: ____________________________
My due date: __________________________
My provider’s name: _____________________
Provider’s number: ______________________
My partner’s name: ______________________
Refer to my baby as: _____________________
(baby’s name, son, daughter, your baby)

Pain Medication
When it comes to pain medication I request (check all that apply):

___ Shots through the IV of medication such as Demerol or Stadol
___ An epidural as soon as possible
___ Do not offer pain medication, let me ask for it if I need it
___ No medication at all, I want a drug free birth
___ Other: _______________________________________________
________________________________________________________

Episiotomies and Tearing
When it comes to delivery I prefer (check all that apply):

___ An episiotomy
___ To tear naturally
___ An episiotomy ONLY if necessary
___ Perineal massage
___ Pain medication for stitching up a tear or cut
___ Other: _______________________________________________
________________________________________________________

Visitors
When it comes to visitors during labor and deliver, I prefer (check all that apply):

___ Please allow all visitors to come and go as they please
___ I only want visitors during the early stages of labor
___ No visitors except for my birth partner
___ Do not allow these people: ______________________________
___ Other: _______________________________________________
________________________________________________________

Immediately After Delivery
Immediately after I deliver I prefer (check all that apply):

___ Please lay my baby on my chest immediately
___ Please clean up my baby before bringing him/her to me
___ We are donating/banking the cord blood
___ Please allow the cord to stop pulsating before cutting cord
___ Please allow my partner to cut the cord
___Please allow my partner to stay with the baby
___ Please allow me to breastfeed immediately before you take baby to be cleaned, get eye drops etc.
___ Other: _______________________________________________
________________________________________________________

C-Section
In the case where a c-section is necessary, I prefer the following (check all that apply):

___ Allow my partner to accompany baby to the nursery and stay with the baby at all times while I am being stitched up
___ Bring my baby to my recovery room as soon as possible so I may bond and attempt to nurse/feed
___ Wait till I get situated in my room before you bring me my baby
___ Do not give my baby sugar water or formula in the nursery whether it is through a dropper, or bottle
___ Go ahead and feed my baby in the nursery
___ Other: _______________________________________________
________________________________________________________

Postpartum Care
For my postpartum care, I prefer (check all that apply):

___ I want my baby to room in at all times
___ I would like my baby to go to the nursery at my request
___ Please administer all tests and medications to my baby in my room
___ Allow my partner to have access to the nursery and to be with the baby at all times when the baby is removed from my presence
___ I want my birth partner to be allowed to stay the night
___ I want family and friends, including other children to have free reign when it comes to visitation
___ Other: _______________________________________________
________________________________________________________

Feeding
When it comes to feeding my baby, I prefer (check all that apply):

___ I will be breastfeeding only
___ I will be breastfeeding and supplementing with formula
___ I will be formula feeding only
___ If in the nursery, bring my baby to me to feed on demand
___ Please feed my baby while in the nursery
___ Do not give my baby sugar water or formula in any situation whether via bottle, dropper or other method
___ Other: _______________________________________________
________________________________________________________

Miscellaneous
Other things that are important to me include (check all that apply):

___ I want to take pictures during labor/birth
___ I want to take video during labor/birth
___ I prefer to be able to eat/drink during labor
___ I want to have the freedom to move around until/unless I request pain medicine
___ I want to be able to take a bath or shower to relieve pain during labor
___ Other: _______________________________________________
________________________________________________________

Thank you for taking the time to read my birth plan. Please keep me informed of anything that comes up during labor that might cause me to deviate from my birth plan.

Thanks,

___________________________
Sign your name

___________________________
Print your name

___________________________
Date