An Easy Interactive Checklist

Summarizing your birth preferences is easy with our interactive checklist! Simply fill in the blanks at the top of the plan below, then check the items you would like to see printed on your birth plan. Each section also offers 2 to 4 blank text boxes for you to fill in anything else you would like to add.

woman typing birth plan

A few important notes

The reason for creating a birth plan is so that everyone understands your hopes and desires for labor and birth. It is a great place to begin discussions with your caregiver(s). This is not a contract, but a statement of your preferences. (Click here for a great article about birth plans.)

Birth plans are best kept short and to the point -- lots of details may be lost on medical support staff. You may wish to create two plans: one for you and your support team (coach, doula, etc.) and another, more concise document (about a page long) for your caregiver and the hospital/birth center staff.

It is very importantthat you talk about the procedures and/or choices that appear your plan with your caregiver(s). Not only do obstetric practices often vary by caregiver, hospital, state and country, there are often important factors involved. It is your responsibility to evaluate and understand each choice you make.

Instructions

On the plan below, all section headings are checked by default. If you do not select any of the options underneath a particular heading (and keep the blank boxes clear), uncheck the heading box in order to avoid having a spare heading with no additional text.

When you're done, press the "create" button at the end of the page! Save the finished plan to your hard drive as a .htm or .html file or print it out.

Start here

Birth plan title:
Birth Plan
Our wishes for Childbirth
My wishes for Childbirth
Birth Preferences
Preferences for Labor and Birth
Our Birth Choices
Font face:
Times New Roman
Arial, Helvetica
Verdana
Trebuchet MS
Your full name: 
Name of your caregiver:
Name of Hospital/Birth Center: 
Due date: 
Coach/main support (i.e. my husband, my coach, James, my mother): 
How do you want the plan to refer to your baby? (our baby, my daughter, the babies)

Date:

Greeting:

Introduction: (please feel free to modify/delete any of this text)


Please Note
I have tested positive for Group B Strep.
My bloodtype is Rh- (Rhesus Negative).
I have gestational diabetes.
I am diabetic.
I am hard of hearing.
My vision is impaired.
I would like to wear contact lenses or glasses at all times when conscious.
Notes: 
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Labor (Click here for articles about labor and birth)
Please perform no routine prepatory tasks (shaving, enema, etc.), unless requested.
I would like to have an enema upon admission to the hospital.
I expect that doctors and hospital staff will discuss all procedures with me before they are performed.
I would like to be free to walk, change positions and use the bathroom as needed or desired.
I prefer to wear my own clothes, rather than a hospital gown.
I prefer to eat and drink throughout labor, as desired.
I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips).
So I can stay as mobile as possible, I would prefer to have a heparin lock adminstered instead of an IV.
Please do not administer an IV or heparin lock unless there is a clear medical indication that such is necessary.
I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions.
I would like to play my own music.
Please limit the number of vaginal exams.
I wish to labor freely in the birthing tub or shower.
As long as the baby is doing well, I prefer that fetal heart tones be monitored intermittently with an external monitor or doppler, even if the membranes have ruptured.
If fetal distress is suspected and time permits, I would like confirmation of this with a fetal scalp blood sample before proceeding with other interventions.
Please allow me to vocalize as desired during labor and birth without comment or criticism.
I do not mind observation by students, interns or staff.
Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.
To preserve my privacy and dignity, I would prefer that everyone knock before entering.
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Labor Induction/Augmentation
I would like to avoid induction unless it is medically necessary.
As long as the baby and I are healthy, I do not want to discuss induction prior to 42 weeks.
If my pregnancy progresses past 40 weeks, I would prefer to base the decision to induce on the results of the baby's biophysical profiles, not on my own personal discomfort or impatience.
I would like to try alternative means of labor augmentation, like walking or nipple stimulation, before pitocin or artificial rupture of membranes is attempted.
If induction is necessary, I would like to attempt it with prostaglandin gel or another means before pitocin is administered.
If induction is attempted, but fails, I would like to come back at another time rather than pursue further intervention (assuming my membranes are intact and that waiting presents no danger to the baby or myself).
Please do not rupture my membranes artificially unless medically indicated.
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Anesthesia/Pain Medication
Please do not offer anesthesia/analgesia unless I ask for it.
If I ask for pain relief, please feel free to offer nonmedical choices for coping and/or remind me how close I am to the birth.
I would like to avoid all narcotics, if possible.
I prefer an epidural to narcotic pain medication.
If pain relief is considered, I would like to try a narcotic before an epidural.
I would like to try having narcotics-only administered in the epidural line before progressing to full anesthesia.
I would like to have an epidural as soon as permissable.
I would like to have the epidural catheter placed upon my admission to the hospital.
I would like to have a light dose (walking) epidural.
I would like the epidural to wear off slightly as I approach full dilation and the pushing stage.
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Cesarean Section Delivery
I feel very strongly that I would like to avoid a cesarean delivery
If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making.
I would like (coach) to be present during the surgery.
Please explain the surgery to me as it happens.
I would prefer general anesthesia in an emergency only.
I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.
I would prefer spinal anesthesia for the procedure.
I would like to have a respectful atmosphere without chatter during any part of the surgical procedure.
If possible, please do not strap my arms to the table during the procedure.
If conditions permit, I would like to be the first to hold the baby after the delivery.
If possible, I would like to breastfeed the baby immediately after the birth.
If conditions permit, the baby should be given to (coach) immediately after the birth.
I would like our plans outlined here for after the birth to be followed as closely as possible.
Please lower the screen just before delivery so I may see the birth of the baby
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Perineal Care
I prefer not to have an episiotomy unless it is medically indicated.
To avoid episiotomy or tearing, (coach) or my labor assistant will perform perineal massage with oil and apply hot compresses.
To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.
I would rather tear than have an episiotomy.
I would rather have an episiotomy than risk a tear.
Please administer local anesthesia when repairing any episiotomy or tear(s).
Please suture tears only if necessary.
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Delivery
Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase.
I prefer to push or not push according to my instincts and would prefer not to have guidance or coaching in this effort.
I do not want to use stirrups while pushing.
I would like the freedom to push and deliver in any position I like.
I would appreciate help from (coach) and staff supporting my legs as I push.
I would like to deliver in a birthing pool and have made arrangements to rent one for the birth.
I would like to have a mirror available and adjusted so I can see the baby's head crowning.
I would like the opportunity to touch my baby's head as it crowns.
I would like a soothing environment during the actual birth, with dim lights and quiet voices.
I would like (coach) to help catch the baby.
I would like (other) to help catch the baby.
I would like to help catch the baby.
I would like to have the birth recorded with photographs, video tape and/or tape recording.
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After birth
Please place the baby on my stomach/chest immediately after delivery.
I would like to breastfeed the baby immediately.
(coach) would like the option to cut the cord.
(other) would like the option to cut the cord.
I would like the option to cut the cord.
Please allow the umbilical cord to stop pulsating before it is cut.
I have made arrangements for donation of the umbilical cord blood.
I have made arrangements to bank the umbilical cord blood.
I prefer to wait for spontaneous delivery of the placenta and do not want a routine injection of pitocin.
Please show me the placenta after it is delivered.
Please remove my IV/Heparin lock/catheter as soon as possible after delivery.
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Newborn Care
I would like to hold the baby skin-to-skin during the first hours to help regulate baby's body temperature.
I would like to hold the baby through delivery of the placenta and any repair procedures.
Please evaluate and bathe the baby at my bedside.
If possible, please evaluate the baby on my abdomen.
If the baby must go to the nursery for evaluation or medical treatment, (coach), or someone I designate, will accompany the baby at all times.
I would prefer to bathe the baby myself, at my discretion.
Please delay eye medication for the baby until we are well past the initial bonding period (a couple hours after the birth).
If available, would prefer erythromycin eye treatment or other antibiotic eye drops instead of silver nitrate.
I would like to waive the administration of eye antibiotics.
I would prefer to have Vitamin K administered orally.
I would like to waive the administration of routine Vitamin K, unless medically indicated.
I would like to defer the PKU screening.
I would like to defer the following vaccinations:
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Postpartum (Click here for postpartum features)
I would prefer not to be catheterized until I've had some private time to attempt urination on my own.
If available, I would prefer a private room.
I would like to have the baby room-in with me at all times.
Once I've had time to recover, I would like the baby to room-in with me.
I would like the baby to room-in with me during the day, but stay in the nursery at night.
I would like the baby in the nursery at night, but brought to me for breastfeeding on demand.
I would like the baby in the nursery and brought to me on request and for breastfeeding.
I would like my (coach) to room-in with me.
I would like (other) to room-in with me.
I would like my other children to have free visitation access.
Assuming I feel up to it and the baby is healthy, I would like to be released from the hospital as soon as possible following the birth.
I would like permission for access to my chart and the baby's chart.
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Breastfeeding (Click here for information about breastfeeding)
I plan to breastfeed and want to nurse immediately following the birth.
Please do not give the baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity.
Unless I am unable to give my consent, please do not give the baby any supplements without first informing me of the reason(s) and seeking my consent.
Please do not give the baby a pacifier.
I would like to know more about breastfeeding.
I would like to meet with the staff lactation consultant.
I do not plan to breastfeed.
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Additional notes
I would like to take still photographs during labor and the birth.
I would like to make a videorecording of labor and/or the birth.
I am not planning to have the baby circumcised.
I am planning for the baby to be circumcised before we check out of the hospital. (Note: Do not waive Vitamin K shot in this event)
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If you do not select any of the options underneath a particular heading (and keep the blank boxes clear), uncheck the heading box in order to avoid having a spare heading with no additional text.

Tags: birthplan


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