Free *Printable* Birth plan

 

 

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:

  1. Systemic IV meds:   Yes/No
  2. Epidural/spinal:   Yes/No
    1. Type of epidural: __________________________________________________________
      • Narcotic (Ultra-low/walking)
      • Local/Narcotic mix (light epidural)
      • Local epidural
      • Intermittent epidural
      • Continuous epidural
      • PCA (patient controlled analgesia) pump

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

  1. Latent (0-3cm)
  2. Active (4-7cm)
  3. 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

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