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