K - Birth Plan Checklist

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Birth Plan: Checklist Style

Fill out this page according to your own wishes for your birth. Keep in mind that you might
not be able to follow every wish on this page depending on hospital policy or if complications
arise during your labor. Share your plan with your support team, practitioner, and labor nurse.
My Name: _______________________________________________________________
Due Date: _______________________________________________________________
Labor Companions:________________________________________________________
Healthcare Provider: _______________________________________________________
Labor n I would like as much monitoring as possible.

n Dim Lighting n Quiet n I prefer a method that allows me to remain mobile.
n Play Music n Wear my own clothing n Fetal monitoring in bed is fine with me.
n Bring things in from home like blankets or photos
n Aromatherapy scents Pain Relief
n Video/photos taken by______________________ Nonmedical Options
n Relaxation n Changing positions/walking
Mobility n Visualization n Massage n Fitness ball
n I prefer to maintain all mobility, including walking n Breathing n Tub/shower n Hot and cold packs
and changing positions. Medical Options
n I prefer to be able to move around in bed only and n Analgesic n Epidural anesthesia
get up to use the bathroom. n I prefer that pain medication only be offered to me
n Mobility is not important to me, and I understand at my request.
that if I get an epidural I may be confined to bed
and need a urinary catheter to go to the bathroom.
Augmentation
Methods to Speed Up Labor
Hydration and Nourishment
If my labor slows down, I would:
n I would like to eat light snacks and drink clear
n First like to try nonmedical methods like walking
fluids whenever possible during labor.
and using upright labor positions.
n It would not bother me to have an IV for hydration
n Prefer that my practitioner breaks my bag of
if necessary.
waters.
n I prefer a saline lock if the placement of an IV is
n Prefer that my bag of waters breaks on its own.
required by my hospital, but no fluids or
medication are needed during my labor. n Not mind having an IV of Pitocin and understand
the benefits and risks involved.
n Prefer to receive an IV of Pitocin only after all
Monitoring other methods are tried, and only if medically
n I prefer my baby to be monitored as minimally as necessary.
possible.
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Birth Plan: Checklist Style continued

Pushing n I want to room in with my baby.
n I prefer to wait to push until I feel the urge or until n If I have a boy, I prefer to have him circumcised.
my baby descends. n I do not want my baby boy to be circumcised.
n I would like to use a variety of positions during n I would like my baby’s hearing to be tested.
pushing.
n I would like a mirror placed at the foot of the bed
so I can watch my baby’s birth. In Case of a Cesarean
n I would like to push whenever I feel like it. n I would like _____________________ to
accompany me during surgery.
n I would like to be directed as to when to push.
n If possible, I would like two people to accompany
n I prefer any natural tearing over an episiotomy. me.
n I would not mind having an episiotomy. n If anesthesia is a choice for me, I would prefer an
n I would like to avoid forceps and/or vacuum epidural.
extraction unless absolutely necessary. n If anesthesia is a choice for me, I would prefer a
n I would like to touch my baby’s head as it crowns. spinal.
n I would like my healthcare provider to hand me n If possible, I would like music played in the
the baby immediately if there aren’t any operating room.
complications. n I would like the drape/screen lowered during
surgery so I can see the birth.
Birth and Baby Care n I would like the surgeon to describe the surgery as
n I would like to hold my baby skin to skin he or she goes along.
immediately after birth and breastfeed as soon as n I would like to have video or photos taken.
possible. n I would like my support person to cut the cord.
n I would like __________________ to cut the n I would like to have at least one arm released so I
umbilical the cord. can hold my baby right away.
n I prefer to have the cord cut immediately. n I would like to breastfeed as soon as possible in the
n I would like to wait to have the cord cut until the recovery room.
baby receives all the blood from the placenta.
n I would like to donate the umbilical cord blood.
n I would prefer that routine hospital procedures be
done while I hold my baby if possible.
n I would like all routine tests, shots, and procedures
for my newborn.
n I prefer to choose the tests that are done and
discuss it with my baby’s pediatrician ahead of
time.
n I am breastfeeding exclusively and don’t want my
baby to be given pacifiers, bottles, or formula.
n I plan to formula feed only.
n I prefer a combination of breastfeeding and
formula feeding.
Copyright © 2010 InJoy Productions, Inc. All rights reserved – Permission to copy granted.

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Birth Plan: Checklist Style

Due Date: _______________________________________________________________

Healthcare Provider: _______________________________________________________

Labor n I would like as much monitoring as possible.

Birth Plan: Checklist Style continued

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