Birth Plan Worksheet This worksheet should serve as a guideline and a beginning point for a clear conversation with your medical provider, doula, and support team. All medical decisions are made between you and your medical provider, but making sure your whole team is aware of your hopes can help ensure a positive birth experience. Depending on where you are planning on giving birth, some of these questions may not apply, but it's always helpful to consider your preferences even when changes to the plan are required. Once you submit your answers, you will receive a copy of your Birth Plan by e-mail. First Name Last Name Email Phone Provider/Practice Name Planned Birth Location Estimated Due Date Partner Name (if applicable) Doula Name (if applicable) Will anyone else be at the birth? If so, who? What appeals to you for your birth environment? Dim LightingQuiet VoicesMusicWhite Noise MachineEssential Oil Diffuser Which coping strategies would you like to use? Doula SupportDeep BreathingBath/ShowerMassageAcupressureReflexologyHypnobirthingTENS Machine How do you feel about eating during labor? I would prefer to eat unrestricted throughout labor.I am okay with just drinking fluids.I am okay with just ice chips and IV hydration. How do you feel about hydration during labor? I would like to drink to thirst (hydrate myself) without an IV catheter in place.I am okay with having an IV catheter (saline lock) in place and hydrating myself.I am fine with continuous IV fluids. What positions would you like to labor in? Any position that feels right to me.UprightWalkingHands and KneesSittingBirth BallSide-LyingI am okay with laboring in bed only. Which augmentation methods would you like to discuss if your labor is not progressing? Movement/PositioningAcupressureNipple StimulationSex/Orgasm/MasturbationEnemaCastor OilPitocin Which induction methods would you like to discuss if induction is being considered? AcupressureNipple StimulationSex/Orgasm/MasturbationEnemaCastor OilFoley BalloonRupture of Membranes (manually breaking the bag of waters)CervidilCytotecPitocin What are your preferences for fetal monitoring? Intermittent monitoring with handheld DopplerIntermittent monitoring with wireless External Fetal MonitorIntermittent monitoring with wired External Fetal MonitorContinuous monitoring with wireless External Fetal MonitorContinuous monitoring with wired External Fetal Monitor What are your pain medication preferences? No pain medications. Please do not offer me pain medications unless I request them.I want to see how it goes and consider my options.Nitrous Oxide (Laughing Gas)Stadol/DemerolEpidural What pushing positions would you like to try? Whatever feels comfortable.Water BirthPartner Supported PositionUse RebozoBirth StoolHands and KneesSquattingStandingSide-LyingTug of WarSittingUse Squat BarReclined What pushing techniques would you like to try? Exhale PushingBreath-hold PushingSpontaneous PushingNo Directed PushingDirected PushingPush without time limits (as long as baby and I are fine)MirrorTouch baby when low enoughIf using epidural, turn down or turn off for pushing. What would you like to do to avoid/reduce perineal tearing? Perineal MassageWarm CompressEncourage slower pushing for stretching once crowning begins. What are your preferences regarding episiotomy? I would prefer no episiotomy unless medically indicated and discussed with me beforehand.Please discuss with me if an assisted delivery requires episiotomy. What are your preferences regarding assisted delivery (forceps or vacuum extraction)? If possible, I would prefer to try different pushing positions before going to assisted delivery.Please discuss the medical need for vacuum extraction or forceps with me in advance. What is your preference for cord clamping? Delayed (Physiologic) Cord ClampingCollect Cord Blood for BankingDonate Cord BloodWhatever my provider recommends. What are your preferences for the birth of the placenta? I would like to push the placenta out spontaneously after it separates completely.I would like to see the placenta.The placenta can be discarded.I am planning to take my placenta home.I do not wish to see my placenta. How do you feel about postpartum pitocin? I would prefer medications postpartum only if medically necessary.Routine postpartum pitocin is fine with me. If you have a vaginal or perineal tear, what do you prefer? If the tear is small enough, I would prefer not to have stitches.I would prefer to have stitches if advised by my provider.If repair is required, I would prefer to have local anesthetic. What are you preferences in the case of a cesarean? Cesarean should be performed only if absolutely necessary/medically indicated.Epidural/Spinal if possible rather than general anesthesia.Partner/support person and baby in OR for rest of surgery.Partner or support person with me at all times.Arms unrestricted.Skin-to-skin with baby for rest of surgery.Delayed cord clamping if possible.Talk me through the surgery as you are performing it.Baby and I should be together at all times in recovery room to facilitate breastfeeding.If time allows it, I would like to use gauze in the vagina before surgery to populate baby's mouth, nose, and skin with good bacteria asap after birth. Who would you like to catch the baby? Just my provider.I would like to participate in catching the baby.I would like my partner to participate in catching the baby. What are your preferences for the immediate postpartum period? I would like to do skin-to-skin as soon as possible.I would like to do delayed cord clamping.If I cannot be skin-to-skin with baby, I would like my partner to do skin-to-skin until I am able to.I would like to attempt breastfeeding as soon as possible.Please delay any postpartum procedures (Vitamin K, Erithromycin, weighing and measuring, etc.) until baby and I have breastfed and are settled.I would prefer not to bathe the baby for at least 24 hours after the birth. What are your preferences if you and the baby must be separated after the birth? I would prefer for my partner or a support person to go with the baby to the NICU if needed.Please bring me a breast pump as soon as possible if separation is expected to last more than a few hours.Please discuss the feeding plan and do not give the baby formula without discussing with me in advance. Any other details or specific questions for your provider?