Fillable Printable Standard Birth Plan

Standard Birth Plan

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PATIENT LABEL

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Birth Plan

Planning for the birth of your baby is an exciting time. You have many choices to make for your labor,

delivery and postpartum stay with us. The Birth Plan will help you identify and communicate your wishes to

your healthcare team. Please take some time to talk with your spouse/labor support person about the

options you have available to you. Then, fill in this plan and give copies to the following people:

• Your healthcare provider (physician/midwife)

• The staff at the hospital (bring a copy in your labor bag)

Think of the Birth Plan as a way to tell us about your preferences for your birth experience. Please

understand that your options may change due to the medical condition of you or your baby. However, we

will work to honor your choices and include you in any additional decision making related to your care.

We wish you a wonderful Birth-Day!

Preparation for Childbirth

 I attended a prepared childbirth or childbirth update class.

 I attended a breastfeeding class.

 I did not attend any prenatal classes.

Baby’s Gender

 My baby is a boy. His name is ________________________________.

 My baby is a girl. Her name is ________________________________.

 I do not know my baby’s gender. At the time of birth, I would like to have

_____________________________________ announce the baby’s gender.

My labor support

My primary support person will be _________________________________________________

In addition, ____________________________________ will be providing support during labor.

I will have a doula present to help during my labor/birth: _______________________________

Environment in Labor Room

 I will bring my own music.

 I would like to have the lights dimmed.

 I would like to keep the room as quiet as possible.

Hydration/Oral Fluids

A saline lock (an IV catheter capped with a small plug) is the minimum standard of care based on ACOG guidelines.

 I would like to have clear fluids during my labor (examples - water, ice chips, Gatorade®, clear

juices)

 I would prefer to have fluids through an IV

IV fluids will be necessary with an epidural. Please discuss this with your healthcare provider

Fetal Monitoring

 If I meet low risk criteria, I would like intermittent fetal monitoring.

 I would like to have my baby monitored continuously with an external fetal monitor.

www.acog.org

has information about the American College of Obstetricians guidelines for fetal monitoring

Form# 10BIRTHPLAN Rev 9/10

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PATIENT LABEL

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Comfort Measures/Pain Relief

You will receive ongoing support and encouragement throughout labor.

I would like to try the following coping strategies:

 Walking

 Position changes

 Rocking chair

 Birth ball

 Bath/shower/whirlpool tub

 Breathing & relaxation techniques

 Massage

 Other: _______________________________________________________

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Pain Medication (during labor/delivery)

 I plan to labor without the use of pain medication.

 I will ask for pain medication if I need it.

 I would like to have the nurse offer me pain medication.

If I ask for pain medication, I would like to consider using:

 IV medication

 an epidural

Progress of Labor

Rupture of Membranes

 I would prefer to have my membranes rupture naturally, without intervention.

 I think it is fine if my healthcare provider ruptures the membrane.

If labor is not progressing, I would like to try the following:

 Walking with my support person

 Rocking in the rocking chair

 Rupture my bag of waters

 Begin Pitocin (a medication used to stimulate contractions)

Pushing

When it is time to push, I’d like to:

 push instinctively, in response to my body’s cues.

 be coached on when to push and for how long (most common with an epidural).

I would like to use the following positions for pushing:

 semi-reclining

 side-lying

 squatting

 hands and knees

 positions that are comfortable at the time

Warm compresses / perineal massage:

 I would like warm compresses applied to the perineum while pushing.

 I have been using perineal massage to prepare the perineum for birth.

Form# 10BIRTHPLAN Rev 9/10

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PATIENT LABEL

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Vaginal Birth

I would like to:

 view the birth using a mirror.

 touch my baby’s head as it crowns.

 avoid having an episiotomy (an incision to enlarge the vaginal opening for birth).

Other: _________________________________________________________________________

_________________________________________________________________________

Cutting the umbilical cord:

 I would like to have _____________________________________ cut the cord.

 My labor partner does not want to cut the umbilical cord.

Greeting My Baby

I would like to:

 have the baby placed skin-to-skin on my abdomen immediately after birth.

 have my baby cleaned off before being placed skin-to-skin.

 hold my baby as soon as possible, putting off procedures that aren’t urgent.

Infant Feeding

During my stay in the hospital:

 I plan to breastfeed.

 I plan to formula feed.

Circumcision

If my baby is boy:

 I do not want to have him circumcised.

 I would like to have him circumcised at the hospital.

 I will have him circumcised later.

Cesarean Birth

If I have a cesarean birth (surgical delivery of my baby through an abdominal incision), I would like

to have:

 my labor support person present.

 the umbilical cord left long so my labor support person can cut it shorter.

 the baby given to my labor support person as soon as possible.

Other: _________________________________________________________________________

Please help us understand any additional preferences you have for your birth experience. You may have

special routines, traditions or expectations that are part of your beliefs about birth or family/faith heritage.

The more information you can share with us, the better we are able to meet your needs during your stay at

Methodist Women’s Hospital.

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________________________________________________________ __________________________

Patient Signature Date

________________________________________________________ __________________________

Provider Signature Date

Form# 10BIRTHPLAN Rev 9/10