Birth Plan
Mother-to-be: __________________________________________________________________
Father-to-be: ___________________________________________________________________
Due Date: ______________________________________________________________________
Place of Birth: __________________________________________________________________
Medications currently taking:
_________________________________________________________________________________
_________________________________________________________________________________
Emergency contact: ____________________________________________________________
Family doctor: _________________________________________________________________
Medical Conditions: ____________________________________________________________
First Stage (Labor)
List of people allowed in delivery room:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Husband/significant other with me at all times: Yes/no
Be informed of all stages of labor: Yes/No
Lights: Bright/Dim
Students or Residents: Yes/No
Maintain mobility: Yes/No
Continuous monitoring w/ external monitor: Yes/No
Heparin Lock: Yes/No
Pain medications:
- Systemic IV meds: Yes/No
- Epidural/spinal: Yes/No
- Type of epidural: __________________________________________________________
- Narcotic (Ultra-low/walking)
- Local/Narcotic mix (light epidural)
- Local epidural
- Intermittent epidural
- Continuous epidural
- PCA (patient controlled analgesia) pump
- Type of epidural: __________________________________________________________
Relaxation Techniques: Yes/No
- Lights low: Yes/No
- Relaxing music: Yes/No
- Aromatherapy/essential oils or diffuser/incense (lavender/sage/jasmine/rose): Yes/No
- Vitamin B: Yes/No
- Massage: Yes/No
- Acupressure: Yes/No
- Hydrotherapy: Yes/No
- Reflexology: Yes/No
- Movement/changing positions: Yes/No
- Hypnosis: Yes/No
Induction/Augmentation: Yes/No
- Natural: Yes/No
- Pitocin/medication: Yes/No
Be informed of dilation measurement: Yes/No
- Latent (0-3cm)
- Active (4-7cm)
- Transitional (8-10cm)
Second Stage (Birth)
Photos/video: Yes/No
Episiotomy: Yes/No
Directed bearing down: Yes/No
Foot pedals (lay on bed): Yes/No
Mirror during delivery: Yes/No
Cord blood bank: Yes/No
- Name of Blood bank:___________________________________________________
- Who to contact:_________________________________________________________
Delay cord cutting: Yes/No
Partner cut cord: Yes/No
Placenta kept: Yes/No
- Company/person caring for placenta:________________________________________
- Contact person/info:_________________________________________________________
Kangaroo care/skin-to-skin contact: Yes/No
- One or two hours: ________________________________________________________
- Family/friends can or cannot visit during this time: Can/Cannot
Delay eye medication: Yes/No
Medication given after birth to baby: Yes/No
Delay first bath: Yes/No
- Nurse give bath or mother/father give first bath: ________________________________
Breastfeed or Bottle-fed: _________________________________________________________
C-section:
Emergency only: Yes/No
Partner present: Yes/No
Explain surgery as it is happening: Yes/No
Have baby as soon as possible: Yes/No
Baby info:
Breastfed: Yes/No
- Pacifiers allowed: Yes/No
- Glucose water as needed: Yes/No
Bottle-fed: Yes/No
Circumcision: Yes/No
- Family history of Von Willebrand’s disease: Yes/No
- Family history of hemophilia: Yes/No
- Parents present during circumcision: Yes/No
- Type of circumcision: The Gomco clamp/The Mogen clamp/The plastibell technique
Baby in room unless tests are being done: Yes/No
Sick Baby:
Parents transferred with baby: Yes/No
Parents with baby at all times: Yes/No
Unlimited parental visitation: Yes/No
Explain to parents what is going on: Yes/No