There are many decisions, as a couple, that need to be made.
This is a list of most of the common questions or preferences for birth.
Feel free to add your own.
Please mark your preferences and bring this with you to your next prenatal appointment to discuss with your care provider. In addition, present a copy to the nurse upon arrival to Labor & Delivery.
Birth Plan/Preference List Date:____________
Name:______________
Reviewed with:_______________________
During my labor and birth, I plan to have the following people in the room with me:__________________________________________________________________________________
To assist with my comfort, I would prefer:
[ ] Alternative pain relief options (such as breathing, massage, hydrotherapy, position changes).
[ ] I will ask for medication if needed.
[ ] To hear about my medication options if you see that I am having difficulty coping with labor.
[ ] To try IV narcotics
[ ] To try Nitrous Oxide
[ ] An epidural (regional anesthesia)
Other preferences include:
[ ] Intermittent fetal monitoring if it is safe for my baby
[ ] A saline lock placed when my blood is drawn during hospital admission. I understand this will allow IV access for medications and hydration, if needed, but will allow me freedom of movement.
[ ] Not to have an IV placed on admission. I understand that I will need to stay hydrated by drinking clear liquids and may need an IV later in the labor process.
When pushing, I would prefer:
[ ] To “labor down” until I have the urge to push, for a maximum of 1 hour, if it is safe to do so.
[ ] To be offered coaching if progress is slow or pushing is not felt to be effective
[ ] To be given a choice to push in whatever position feels most comfortable as long as it is safe.
[ ] To use a mirror to see the baby as it crowns
[ ] To touch the baby as it crowns
After the birth, I would like:
[ ] A delay in cord clamping, as long as baby is transitioning well
[ ] To have the cord blood collected for banking (I have provided a cord collection kit)
To have my birth partner:
[ ] Cut the umbilical cord
[ ] Stay with the baby during routine care procedures
[ ] Announce the sex or our baby
If a cesarean birth is necessary, I would like to:
[ ] Have my birth companion present: _______________
[ ] Have the baby placed skin to skin post delivery
For my baby:
[ ] I plan to have usual newborn treatments including Erythromycin eye ointment and the Vitamin K injection
[ ] I plan to decline use of Erythromycin eye ointment, but consent to Vitamin K injection.
[ ] I do not consent to Erythromycin ointment and the Vitamin K injection. (I am aware that a pediatrician will speak to me about the risks.)
[ ] I consent to Hepatitis B vaccine in the hospital (usual recommended treatment for newborns)
[ ] I wish to decline Hepatitis B vaccine in the hospital
If I have a boy, I plan to:
[ ] Have him circumcised before leaving the hospital
[ ] Not circumcise
For the baby’s feedings, I plan to:
[ ] Formula feed
[ ] Breastfeed
Birth Plan/Preference List Date:____________
Name:______________
Reviewed with:_______________________
During my labor and birth, I plan to have the following people in the room with me:__________________________________________________________________________________
To assist with my comfort, I would prefer:
[ ] Alternative pain relief options (such as breathing, massage, hydrotherapy, position changes).
[ ] I will ask for medication if needed.
[ ] To hear about my medication options if you see that I am having difficulty coping with labor.
[ ] To try IV narcotics
[ ] To try Nitrous Oxide
[ ] An epidural (regional anesthesia)
Other preferences include:
[ ] Intermittent fetal monitoring if it is safe for my baby
[ ] A saline lock placed when my blood is drawn during hospital admission. I understand this will allow IV access for medications and hydration, if needed, but will allow me freedom of movement.
[ ] Not to have an IV placed on admission. I understand that I will need to stay hydrated by drinking clear liquids and may need an IV later in the labor process.
When pushing, I would prefer:
[ ] To “labor down” until I have the urge to push, for a maximum of 1 hour, if it is safe to do so.
[ ] To be offered coaching if progress is slow or pushing is not felt to be effective
[ ] To be given a choice to push in whatever position feels most comfortable as long as it is safe.
[ ] To use a mirror to see the baby as it crowns
[ ] To touch the baby as it crowns
After the birth, I would like:
[ ] A delay in cord clamping, as long as baby is transitioning well
[ ] To have the cord blood collected for banking (I have provided a cord collection kit)
To have my birth partner:
[ ] Cut the umbilical cord
[ ] Stay with the baby during routine care procedures
[ ] Announce the sex or our baby
If a cesarean birth is necessary, I would like to:
[ ] Have my birth companion present: _______________
[ ] Have the baby placed skin to skin post delivery
For my baby:
[ ] I plan to have usual newborn treatments including Erythromycin eye ointment and the Vitamin K injection
[ ] I plan to decline use of Erythromycin eye ointment, but consent to Vitamin K injection.
[ ] I do not consent to Erythromycin ointment and the Vitamin K injection. (I am aware that a pediatrician will speak to me about the risks.)
[ ] I consent to Hepatitis B vaccine in the hospital (usual recommended treatment for newborns)
[ ] I wish to decline Hepatitis B vaccine in the hospital
If I have a boy, I plan to:
[ ] Have him circumcised before leaving the hospital
[ ] Not circumcise
For the baby’s feedings, I plan to:
[ ] Formula feed
[ ] Breastfeed
