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Create Your Birth Plan
Step 2: Create Your Birth Plan

Below you will find a Birth Plan form. Fill in your answers and click the "Submit" button. You'll then receive your customized birth plan to print out and share with your physician or nurse midwife.

General Information (Required Information)


1. My full name:


2. Name with which I'd like to be addressed:


3. Partner's name:


4. Other support people to be present at birth:


5. Estimated delivery date:


6. Primary caregiver:


7. Prenatal classes I've attended:


8. Date birth plan developed:

Conversations to Have with My Care Providers and Partner


9. During my pregnancy, I will talk to my doctor/nurse-midwife about the following topics:
Positions for pushing and delivering my baby, and what will work best for me.
Ways to start or restart labor, such as breast stimulation, artificial breaking of membranes and Oxytocin/Pitocin.
Assisted birth devices, such as forceps and vacuum extraction.


10. As I'm talking to potential doctors for my baby, I will discuss the following topics to see if our philosophies complement each other:
Opinions on circumcision of boy babies.
Opinions on breastfeeding versus bottlefeeding.
Opinions on immunizations and the use of antibiotics.


11. During my pregnancy, I will talk to my partner about the following topics:
Whether he or she feels comfortable about going into the Cesarean birth suite with me, if a Cesarean is needed.
If a Cesarean birth becomes necessary and the baby needs to be moved to the Newborn Intensive Care Unit, will my partner go with the baby or stay with me for the remainder of the Cesarean delivery and recovery. (Please note that if your partner decides to stay with you, another support person – who is outside of the Cesarean birth suite – can go with the baby to the Newborn Intensive Care Unit.)


During Pregnancy


12. During my pregnancy, I will do the following to maintain confidence in my abilities to give birth and parent my child:
I will talk with other women who have had positive, empowering birth experiences.
I will recite birth affirmations every day (I am strong and competent).
I will learn and practice relaxation techniques and pain-coping skills.
I will learn and practice perineal massage and kegel exercises to help avoid an episiotomy.
I will attend childbirth classes, parenting classes, relaxation classes and support groups that will show me how to become more confident in myself.
I will stay home in early labor, unless otherwise instructed.


13. Other ways I will remain confident as I prepare for labor:

During Labor


Please note:
  • Enemas, pubic hair shaving and IV's are not routine.
  • Underwater births are not available.
  • We welcome you to take pictures and videotape those important moments of your labor/birth and of your newborn. However we do request that you ask permission from your provider and nursing staff before doing so. While we want you to have the opportunity to take pictures and video, we also want to make sure these activities do not interfere with providing safe patient care. Your provider and/or nurse may request that taking pictures or videotaping should not occur at certain times or in certain situations or during certain procedures . We appreciate your cooperation during these times and we will inform you when picture taking and/or videotaping is appropriate to resume.
14. During the beginning of my labor:
I would like to walk and change positions at will throughout labor.
I would like lights in the room to be kept low during my labor.
I will be bringing my own music to play during labor on the CD/tape player provided.
I prefer to wear my own clothes during labor.
I would like to try using the Birth Ball as an option to promote comfort.
I would like to restrict my visitors. I will provide a list of friends and family who may be directed to my room.
I do not wish to have my membranes broken unless signs of fetal stress require internal monitoring.
If my membranes break at the onset of labor I want to wait at least 6-12 hours before artificially starting my labor, if possible.


15. My preference for monitoring:
I do not wish to have continuous monitoring, unless my baby's or my condition requires it.
I do not wish to have internal fetal monitoring unless the baby has shown some signs of distress.


16. The role of my labor support person is the following:
I do not have an identified labor support person.
My labor support person will be there to provide emotional support and physical comfort measures.
My support person will be actively involved during my labor.
My support person will be prepared to make informed decisions about my care during labor, while working closely with the delivery team.


17. Other labor preferences:


18. To help me cope with and manage my pain:
I prefer to avoid any pain medication.
I prefer to try alternative pain coping techniques.
I realize that pain medications are available and I will request them if needed.
Before considering an epidural, I would first like to try an injection of narcotic pain medication.
I would like an epidural at the point when I become uncomfortable.
I would like an epidural as soon as I can.


19. Other pain-coping preferences:

During Delivery and Recovery


20. During my delivery:
Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel an urge to push.
When pushing I would prefer to do what feels best at the time.
I would like to use the squatting bar during my pushing efforts.
I would like a mirror available so I can see the baby's head when it crowns.
I would like to touch my baby's head when it crowns.


21. If given the opportunity, I would like the following person to cut the umbilical cord:


22. Episiotomy preferences:
I would prefer NOT to have an episiotomy unless it is necessary to promote the wellbeing of my baby.
I would like to use perineal massage to help avoid the need for an episiotomy.
If it appears that my perineum may tear, I would prefer an episiotomy.


23. After the birth of my baby, and if the baby is okay:
I would like my baby to be placed on my stomach/chest immediately after birth.
If I am not having excessive vaginal bleeding after delivery, I would prefer not to have an injection of Pitocin.
I would like the opportunity to see the placenta after delivery.
I would like to take my placenta home and would appreciate that it be stored in a safe place until I am discharged from the hospital.


24. Other delivery preferences:


25. Other recovery preferences:

Cesarean Birth


26. In the event I need a Cesarean birth, and it is not an urgent situation:
I prefer to be awake and have regional anesthesia (spinal or epidural).


27. If a Cesarean birth is needed, the following person will be in the surgical suite with me:


28. If the baby is not in distress:
I would like my partner to be present during the baby's initial assessment and for my partner to be the one who brings the baby to me.


29. Other Cesarean birth preferences:

Baby Care


30. I would like the following person to be assisted with giving the baby his/her first bath:


31. If I have a boy, I am planning to have him circumcised.
Yes
No


32. Feeding:
I will breastfeed my baby.
I will formula feed my baby.


33. Visitors:
I would like to limit our visitors so we have time to bond, rest and learn.
We will allow visitors at any time after the birth.


34. Announcing the birth:
I do not want the birth published anywhere.
I plan to have a free Meriter Baby Mail designed for my baby.
I plan to announce our baby's birth in the local newspapers.