Tool: Birth Plan

While much of what happens during delivery is way beyond your (or anyone's!) control, creating a birth plan will at least make your wishes clear. Definitely talk the plan over with your doc -- it's important to make sure you're both on the same page. Also, remember that the options included on our plan may not be available with every doctor or birthing center.

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Birth Plan:

[ ] Full name:

[ ] Partner’s name:

[ ] Today’s date:

[ ] Due date: OR Induction date:

[ ] Doctor’s name:

[ ] Hospital name:

Please note that I:
[ ] Have group B strep
[ ] Am Rh incompatibility with baby
[ ] Have gestational diabetes

My delivery is planned as:
[ ] Vaginal
[ ] C-section
[ ] Water birth
[ ] VBAC

I’d like…:

[ ] Partner:

[ ] Parents:

[ ] Other children:

[ ] Doula:

[ ] Other:

…present before AND/OR during labor

During labor, I’d like:
[ ] Music played (I will provide)
[ ] The lights dimmed
[ ] The room as quiet as possible
[ ] As few interruptions as possible
[ ] As few vaginal exams as possible
[ ] Hospital staff limited to my own doctor and nurses (no students, residents or interns present)
[ ] To wear my own clothes
[ ] To wear my contact lens the entire time
[ ] My partner to film AND/OR take pictures
[ ] My partner to be present the entire time
[ ] To stay hydrated with clear liquids and ice chips
[ ] To eat and drink as approved by my doctor

I’d like to spend the first stage of labor:
[ ] Standing up
[ ] Lying down
[ ] Walking around
[ ] In the shower
[ ] In the bathtub

I'm not interested in:
[ ] An enema
[ ] Shaving of my pubic area
[ ] A urinary catheter
[ ] An IV, unless I’m dehydrated (and a heparin or saline lock IS/IS NOT ok)

I’d like fetal monitoring to be:
[ ] Continuous
[ ] Intermittent
[ ] Internal
[ ] External
[ ] Performed only by Doppler
[ ] Performed only if the baby is in distress

I’d like labor augmentation:
[ ] Performed only if baby is in distress
[ ] First attempted by natural methods such as nipple stimulation
[ ] Performed by membrane stripping
[ ] Performed with prostaglandin gel
[ ] Performed with Pitocin
[ ] Performed by rupture of the membrane
[ ] Performed by stripping of the membrane
[ ] Never to include an artificial rupture of the membrane

For pain relief, I’d like to use:
[ ] Acupressure
[ ] Acupuncture
[ ] Breathing techniques
[ ] Cold therapy
[ ] Demerol
[ ] Distraction
[ ] Hot therapy
[ ] Hypnosis
[ ] Massage
[ ] Meditation
[ ] Reflexology
[ ] Standard epidural
[ ] TENS
[ ] Walking epidural
[ ] Nothing
[ ] Only what I request at the time
[ ] Whatever is suggested at the time

During delivery, I would like to:
[ ] Squat
[ ] Semi-reline
[ ] Lie on my side
[ ] Be on my hands and knees
[ ] Stand
[ ] Lean on my partner
[ ] Use people for leg support
[ ] Use foot pedals for support
[ ] Use a birth bar for support
[ ] Use a birthing stool
[ ] Be in a birthing tub
[ ] Be in the shower

I will bring a:
[ ] Birthing stool
[ ] Birthing chair
[ ] Squatting bar
[ ] Birthing tub

As the baby is delivered, I would like to:
[ ] Push spontaneously
[ ] Push as directed
[ ] Push without time limits, as long as the baby and I are not at risk
[ ] Use a mirror to see the baby crown
[ ] Touch the head as it crowns
[ ] Let the epidural wear off while pushing
[ ] Have a full dose of epidural
[ ] Avoid forceps usage
[ ] Avoid vacuum extraction
[ ] Use whatever methods my doctor deems necessary
[ ] Help catch the baby
[ ] Let my partner catch the baby
[ ] Let my partner suction the baby

I would like an episiotomy:
[ ] Used only after perineal massage, warm compresses and positioning
[ ] Rather than risk a tear
[ ] Not performed, even if it means risking a tear
[ ] Performed only as a last resort
[ ] Performed as my doctor deems necessary
[ ] Performed with local anesthesia
[ ] Performed by pressure, without local anesthesia
[ ] Followed by local anesthesia for the repair

Immediately after delivery, I would like:
[ ] My partner to cut the umbilical cord
[ ] The umbilical cord to be cut only after it stops pulsating
[ ] To bank the cord blood
[ ] To donate the cord blood
[ ] To deliver the placenta spontaneously and without assistance
[ ] To see the placenta before it is discarded
[ ] Not to be given Pitocin/oxytocin

If a C-section is necessary, I would like:
[ ] A second opinion
[ ] To make sure all other options have been exhausted
[ ]To stay conscious
[ ] My partner to remain with my the entire time
[ ] The screen lowered so I can watch baby come out
[ ] My hands left free so I can touch the baby
[ ] The surgery explained as it happens
[ ] An epidural for anesthesia
[ ] My partner to hold the baby as soon as possible
[ ] To breastfeed in the recovery room

I would like to hold baby:
[ ] Immediately after delivery
[ ] After suctioning
[ ] After weighing
[ ] After being wiped clean and swaddled
[ ] Before eye drops/ointment are given

I would like to breastfeed:
[ ] As soon as possible after delivery
[ ] Before eye drops/ointment are given
[ ] Later
[ ] Never

I’d like my family members (NAMES):

[ ] To join me and baby immediately after delivery
[ ] To join me and baby in the room later
[ ] Only to see baby in the nursery
[ ] To have unlimited visiting after birth

I’d like baby’s medical exam and procedures:
[ ] Given in my presence
[ ] Given only after we’ve bonded
[ ] Given in my partner’s presence
[ ] To include a heel stick for screening tests beyond the PKU
[ ] To include a hearing screening test
[ ] To include a hepatitis B vaccine

Please don’t give baby:
[ ] Vitamin K
[ ] Antibiotic eye treatment
[ ] Sugar water
[ ] Formula
[ ] A pacifier

I’d like baby’s first bath given:
[ ] In my presence
[ ] In my partner’s presence
[ ] By me
[ ] By my partner

I’d like to feed baby:
[ ] Only with breastmilk
[ ] Only with formula
[ ] On demand
[ ] On schedule
[ ] With the help of a lactation specialist

I’d like baby to stay in my room:
[ ] All the time
[ ] During the day
[ ] Only when I’m awake
[ ] Only for feeding
[ ] Only when I request

I’d like my partner:
[ ] To have unlimited visiting
[ ] To sleep in my room

If we have a boy, circumcision should:
[ ] Be performed
[ ] Not be performed
[ ] Be performed later
[ ] Be performed with anesthesia
[ ] Be performed in the presence of me AND/OR my partner

As needed post-delivery, please give me:
[ ] Extra-strength acetaminophen
[ ] Percoset
[ ] Stool softener
[ ] Laxative

After birth, I’d like to stay in the hospital:
[ ] As long as possible
[ ] As briefly as possible

If baby is not well, I’d like:
[ ] My partner and I to accompany it to the NICU or another facility
[ ] To breastfeed or provide pumped breastmilk
[ ] To hold him or her whenever possible

-- The Bump Editors

May 29, 2009

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This plan is so incredibley long, would the nurses and staff actually read it? I took the items on here and scaled it down dramatically to cover my primary goals and concerns.

by AmyLou00

That is what I am planning to do. Cut out the unnecessary items or things that aren't my priority... This is my first, so I don't know if they will actually read it or not! I do plan to show it to my OB on one of my next few visits (I am 24 weeks). He can let me know what is reasonable. I hope.

by red1129

They should really create this as a survey type format where you fill in the answers and only the answers that you filled out will print out.

by clburke14

A lot of this stuff seems low priority/could be figured out later (visitation??). But there is no section on infant vaccinations. I've heard of some cases of things like Hep B round 1 being given IN THE DELIVERY ROOM. There is absolutely no reason for that, and actually raises chances of the child developing autism ..... Random people pumping my baby full of chemicals is kind of high on my list. Shots without consent = battery IMO

by Shnazzy

One reason why they have it listed this way, is so that the Dr's and Nurses understand what you DO and DO NOT want to happen before/during/after delivery. Visitation is a good thing to clear up before hand because you're going to be too tired to figure it out after delivery. Also, you might end up having an unexpected visitor show up that you really don't want to be there at the time. Visitation is listed to make sure that you are comfortable with who is where and when. I don't want the family there after delivery, and I'd like sometime to recover and sleep before I start having everyone show up at random times. The nurses AND Dr('s) should go over this with you PRIOR to delivery. Possibly a month prior to make sure everything is understood and settled.

by troubleshooter_4

I'm am most nervous about having all sorts of people there who don't need to be. This will be a private experience for my husband and I so I want the nurses to see my options I left out. Also for vaccinations make sure you check all sides of the facts r/t autism. A study has found autism linked to a gene. Talk to your Dr. about immunizations and a possible delayed immunitzation schedule that spreads out immunizations if you are worried.

by shatzenbiler

Shnazzy -- vaccines do NOT cause autism!! I agree that a vaccine immediately after birth is probably unecessary since he doesn't have a mature immune system yet, so it's questionable how effective the vaccine would be. But there is NO credible evidence linking any vaccine to autism.

by AmyMD

Im 32 weeks and Im unsure if I am going to create a birth plan....Some people say YES its a must others say they dont read it.....I think Im going to just make a brief one and put whats important to me on it

by BabyCakes1089

I am a Labor & Delivery nurse. Although we do our best to accompany both mom & dad's wishes during labor and delivery our number #1 goal is the health & safety of mom and baby. Some of the options you have on here are not supported or practiced in a lot of hospitals, as well, a lot of the options you give the parents to choose from are far from what is medically safe or the priority for mom and/or baby. Last but not least, the spelling/ grammar is incorrect on many things through out this birthing plan. I would suggest that if you decide to keep this birthing plan available for mothers to use, then add the risks/benefits to mom and/or baby for each option. That way parents are aware of the risks they will be taking by refusing certain options or choosing other options instead. Thank you.

by FutureMrsHinkle

While there are a few specifications I will be discussing w/ my OB over the coming months, like no Hep B vaccine immediately after birth and how I will manage the pain, the rest seems like extraneous BS that should be left to the experts. I did not go to school for 8 years and therefore I have no right to tell the DOCTOR what type of fetal monitoring I want...

by BGo

Thanks for making this birth plan tool available. We'll get here the things that are necessary to us. Awesome post. A job well done to you. Please keep informing us like this one. Great job! Any Lab Test Now

by lesterking214