Birth Plan Worksheet
NAME: ______________________________________________________________________ATTENDANTS
I'd like the following people to be present during labor and/or birth:
Partner: ___________________________________________________________
Friend/s: __________________________________________________________
Relative/s: _________________________________________________________
Doula: ____________________________________________________________
Children: __________________________________________________________AMENITIES
I'd like to:bring music
dim the lights
wear my own clothes during labor and delivery
take pictures and/or video during labor and delivery
HOSPITAL ADMISSION & PROCEDURES
I'd like the option of returning home if I'm not in active labor.
Once I'm admitted, I'd like:my partner to be allowed to stay with me at all times
only my practitioner, nurse, and guests to be present (i.e., no residents,medical students, or other hospital personnel)
to wear my contact lenses, as long as I don't need a c-section
to eat if I wish toto try to stay hydrated by drinking clear fluids instead of having an IV
to have a heparin or saline lockto walk and move around as I choose
OTHER INTERVENTIONS
As long as the baby and I are doing fine, I'd like to:have intermittent rather than continuous electronic fetal monitoring
be allowed to progress free of stringent time limits and have my laboraugmented only if necessaryBabyCenter Birth Plan worksheet – page 2
LABOR PROPS
If available, I'd like to try a:birthing stool
birthing chairsquatting bar
birthing pool/tub
I'd like to bring the following equipment with me:birthing stool
beanbag chairbirthing pool/tub
other: ____________________________________________________________
PAIN RELIEF
I'd like to try the following pain-management techniques:acupressurebath/shower
breathing techniques/distraction
hot/cold therapy
self-hypnosis
massagemedication
other: ____________________________________________________________
Please don't offer me pain medication. I'll request it if I need it.
If I decide I want medicinal pain relief, I'd prefer:regional analgesia (an epidural and/or spinal block)systemic medication
PUSHING
When it's time to push, I'd like to:do so instinctively
be coached on when to push and for how longbe allowed to progress free of stringent time limits as long as my baby and
I are doing fine
I'd like to try the following positions for pushing (and birth):semi-reclining
side-lying position
squattinghands and knees
whatever feels right at the timeBabyCenter Birth Plan worksheet – page 3
VAGINAL BIRTH
During delivery, I'd like:to view the birth using a mirror
to touch my baby's head as it crowns
the room to be as quiet as possible
to give birth without an episiotomy
my partner to help "catch" our baby
After birth, I'd like:to hold my baby right away, putting off any procedures that aren't urgent
to breastfeed as soon as possible
not to get oxytocin (Pitocin) after I deliver the placenta unless it'snecessary
to wait until the umbilical cord stops pulsating before it's clamped and cut
my partner to cut the umbilical cord
C-SECTION
If I have a c-section, I'd like:my partner present at all times during the operation
the screen lowered a bit so I can see my baby being delivered
the baby to be given to my partner as soon as he's dried, if appropriate
to breastfeed my baby in the recovery room
CORD BLOOD BANKING
I'm planning to:
donate cord blood to a public bankbank cord blood privately
neither
POSTPARTUM
After delivery, I'd like:all newborn procedures to take place in my presence
my partner to stay with the baby at all times if I can't be there
to stay in a private room
to have a cot provided for my partner
I'd like:
24-hour rooming-in with my baby
my baby to room-in with me only when I'm awake
my baby brought to me for feedings only
to make my decision later depending on how I'm feelingmy other children brought in to see me and meet the new baby as soon as
possible after the birth.

BabyCenter Birth Plan worksheet – page 4
FEEDING ISSUES
I plan to:breastfeed exclusively
combine breastfeeding and formula-feeding
formula-feed exclusively
Do not offer my baby:
formulasugar watera pacifier
CIRCUMCISION
If my baby's a boy:
I want him to be circumcised at the hospital
I'll have him circumcised later
I don't want him circumcisedDISCHARGE
I'd like to:be discharged from the hospital with my baby as soon as possible
stay at the hospital as long as possible
wait and see how I feel before deciding about the timing of hospitaldischarge