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
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

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

Mommy Cayla

Free Printable Birth plan