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# Birth Plan

Your name: Name of your ob-gyn: Name of your baby's doctor: Type of childbirth preparation:

# Labor

Choose as many as you wish:

  • I would like to be able to move around as I wish during labor.
  • I would like to be able to drink fluids during labor.

I prefer:

  • An intravenous (IV) line for fluids and medications
  • A heparin or saline lock (this device provides access to a vein but is not hooked up to a fluid bag)
  • I don't have a preference

I would like the following people with me during labor (check hospital or birth center policy on the number of people who can be in the room):

It's OK - [ ] /not OK - [ ] for people in training (such as medical students or residents) to be present during labor and delivery.

I would like to try the following options if they are available (choose as many as you wish):

  • A birthing ball
  • A birthing stool
  • A birthing chair
  • A squat bar
  • A warm shower or bath during labor. I understand that a bath would be used only for the first stage of labor, not during delivery.

# Anesthesia Options

Choose one:

  • I do not want anesthesia offered to me during labor unless I specifically request it.
  • I would like anesthesia. Please discuss the options with me.
  • I do not know whether I want anesthesia. Please discuss the options with me.

# Delivery

I would like the following people with me during delivery (check hospital or birth center policy):

  • I prefer to avoid an episiotomy unless it is necessary.
  • I have made prior arrangements for storing umbilical cord blood.

For a vaginal birth, I would like (choose as many as you wish):

  • To use a mirror to see the baby's birth
  • For my labor partner to help support me during the pushing stage
  • For the room to be as quiet as possible
  • For one of my support people to cut the umbilical cord
  • For the lights to be dimmed
  • To be able to have one of my support people take a video or pictures of the birth. (Note: Some hospitals have policies that prohibit videotaping or taking pictures. Also, if it is allowed, the photographer needs to be positioned in a way that does not interfere with medical care.)
  • For my baby to be put directly onto my chest immediately after delivery
  • To begin breastfeeding my baby as soon as possible after birth

In the event of a cesarean delivery, I would like the following person to be present with me:

  • I would like to see my baby before my baby is given eye drops.
  • I would like one of my support people to hold the baby after delivery if I am not able to.
  • I would like one of my support people to go with my baby to the nursery.
  • I would like my support person to know what shots my newborn will receive.

# Baby Care Plan

# Feeding the Baby

I would like to (check one):

  • Breastfeed exclusively
  • Bottle-feed
  • Combine breastfeeding and bottle-feeding It's OK to offer my baby (check as many as you wish):
  • A pacifier
  • Sugar water
  • Formula
  • None of the above

# Nursery and Rooming-In

If available at my hospital or birth center, I would like my baby to stay (check one):

  • In my room with me at all times
  • In my room with me except when I am asleep
  • In the nursery but be brought to me for feedings
  • I don't know yet. I will decide after the birth.