Worksheet Template For Preparing Your Birth Plan With Samples


Pregnancy, Childbirth, and the Newborn
8: p
lanning for
irth and
Work Sheet for Preparing Your Birth Plan
You might find this work sheet helpful as you prepare your birth plan. Place a plus sign (+) by the items that you clearly want, and
a minus sign (-) by items you want to avoid unless medically necessary. Put a question mark by items you are unsure about, and
plan to learn more about those options.
Once you have completed this work sheet, write a short description of the roles you envision for yourself, your partner, your
doula or other helpers, and your caregivers (the approach you prefer). Then prepare a draft of your birth plan that consolidates
and generalizes your preferences for discussion with your caregiver.
Options for Normal Labor and Birth
First Stage
Presence of partner/others
Positions for labor (pages 238–240)
__ Partner
__ Freedom to change positions, stand, and/or walk around
__ Doula (page 20)
__ Postural aids (birth ball, bathtub, beanbag chair, or other)
__ Friends or relatives
__ Children (page 438)
Vaginal exams (page 181)
Monitoring fetal heart rate (pages 182–183)
__ At mother’s request or if needed for clinical decision
__ Auscultation with stethoscope or ultrasound stethoscope
__ As few different examiners as possible
__ Intermittent external electronic fetal monitoring (EFM)
__ At caregiver’s discretion
__ Continuous EFM with telemetry
__ Continuous electronic monitoring (internal or external)
Food/fluids (pages 228–229)
Pain relief (chapters 12 and 13)
__ Eat and drink as desired
__ Emotional support and self-help measures
__ Water, juice, Popsicles, ice chips
__ Relaxation, breathing, positions, comfort measures
__ Saline (or Heparin) lock
__ Bathtub, whirlpool, or shower
__ Intravenous (IV) fluids
__ Medications (narcotics) and/or anesthesia (epidural or other)
Second Stage (pushing and birth of baby)
Position for pushing and for birth (pages 190 and 240)
Care of perineum at birth (pages 193 and 292)
__ Warm compresses, controlled pushing, positions
__ Mother’s choice of positions
__ No episiotomy (willing to risk having a tear)
__ Gravity-enhancing positions
__ Decision left to caregiver
__ Caregiver’s choice of positions
__ Episiotomy
__ Forceps or vacuum extraction
Expulsion techniques (pages 189–190)
Bed/equipment for pushing and for birth
__ Spontaneous bearing down
__ Birth stool, squat bar, bathtub, floor
__ Delayed pushing (if epidural used)
__ Birthing bed
__ Directed pushing
__ Delivery table with or without stirrups
__ Prolonged breath holding and straining
Third Stage and First Hours after Birth
Immediate care of baby (pages 195–198)
Warmth of baby (page 195)
__ Delay clamping and cutting the cord
__ Baby skin-to-skin with mother
__ Partner cuts cord
__ Wrapped in warm blanket, held by parent
__ In parent’s arms for observation and exam
__ In heated bassinet in mother’s room
__ Near parents in bassinet or isolette
__ In special heated unit in nursery
__ In nursery for observation, weighing, and first bath
Clearing baby’s airway (page 195)
Cord blood collection (page 198)
__ Suction only if necessary
__ Not planned
__ Suction with bulb syringe almost immediately
__ Public cord blood bank donation
__ Private or family cord blood collection and storage
Third stage and first hours after birth
Eye care and vitamin K (pages 363–364)
__ At end of first hour after birth
__ Use of nonirritating antibiotic agent (for eye care)


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