Worksheet Template For Preparing Your Birth Plan With Samples printable pdf download

Pregnancy, Childbirth, and the Newborn

8: p

hapter

lanning for

irth and

ost

artum

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)

Worksheet Template For Preparing Your Birth Plan With Samples

Related Articles

Related forms

Related Categories