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Birth Plan Worksheet

The following is a list of options that may be available during your labor, delivery, and postpartum period should everything proceed as expected. This is designed as a communication tool between you, your partner, and your care provider. Please use this to help formulate your own Birth Plan. Cold/Heat Would like to take home Birth Site: Limit vaginal exams Home Epidural Following Delivery: St. Elizabeths Immediate, extended skin to BryanLGH Narcotics skin contact with Mother Access to food & beverages Care Provider: Video/Photos Family Practitioner Suctioning/warming of baby Midwife Membranes: while held by mother: Obstetrician Rupture Naturally Thermal Regulation Perinatologist Rupture Artificially Bath/No Bath Warmed blankets People Present at Birth: Second Stage Labor: Tea pack for mother Partner Delivery Options: Prophylactic eye treatment Doula Immediate/Delayed Water Birth Grandparents Hepatitis B Vaccine Video/Photos Siblings Blood Sugar Music Students Squat Bar Coach-Directed Pushing Postpartum: Early Labor: (val salva) Early release from hospital Labor at home as long Instinctive Pushing Stay in hospital as long as as possible. Use of a mirror possible Arrive early and settle in Touch babys head at Induction/Augmentation crowning Location of Baby: Nipple Stimulation Perineal massage Stay in mothers room Acupuncture Episiotomy Brought in as necessary Prefer to tear Hospital Labor & Preparation: Method of Feeding: Own clothes/Hospital gown Delivery Position: Breastfeeding Only IV/Saline Well Semi-Sitting Bottle feeding No IV Reclining on side Combination of Both Strep B? Options Modified Squatting Supported Standing Squat Diapering: First Stage Labor: Hands and Knees Disposable Electronic Fetal Monitor: Laying down Cloth Internal/External Effective Communication Umbilical Cord: Continuous/Intermittent Telemetry Clamp after pulse ceases Baby Exams: To be cut by: Family member accompanies Would like to have: baby at all times Sex of Baby: Music Baby can be Labor Ball Already known moved/accompanied by Essential Oils To be announced by: hospital staff Shower/Tub Babys Doctor: Placenta: Walk Natural delivery Acupuncture Nursery Procedures: Accelerated delivery Massage Pacifier Would like to see Position changes Sugar Water Would like to make a print Rebozo Circumcision

Birth Plan Worksheet


The following is a list of options that may be available during your labor, delivery, and postpartum period should everything proceed as expected. This is designed as a communication tool between you, your partner, and your care provider. Please use this to help formulate your own Birth Plan. Bath/No Bath