There are many decisions, as a couple, that need to be made. 
This is a list of most of the common questions or preferences for birth. 
​Feel free to add your own.  

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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

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