Labor And Birth Plan printable pdf download

BIRTH PLAN FOR ____________________________________

DUE DATE ________________________

The midwives would like to make your birth experience as positive and personalized as it can be. To help, please give some

thought to what is important to you during the birth process and then fill out this form. This is not meant to be a contract or a list

of demands but a way of communicating your values, preferences and concerns. It will be used as a guide to discussion during

pregnancy and is a quick reference for the midwives and hospital personnel during your labor and birth.

LABOR AND BIRTH PLAN

1. Who will accompany you in labor? _____________________________________________________________

2. What can I do to make the birth experience enjoyable for you and your support person?

__________________________________________________________________________________________

3. Describe the atmosphere that would make you the most comfortable in labor, for example: birthing room, dim

lighting, soft music, quiet voices, walking or showering during labor, if possible, etc.

4. Describe your feeling toward:

Continuous fetal monitoring ____________________________________________________________

IV s _______________________________________________________________________________

Artificial rupture of membranes _________________________________________________________

Positioning during labor _______________________________________________________________

Medications _________________________________________________________________________

Epidural anesthesia ___________________________________________________________________

Waterbirth/Water Labor _______________________________________________________________

ú Camera

ú Camcorder

ú Ipod

5. What things do plan to bring from home? (Please check)

ú CD player w/CD s

ú Comfort Items: Pillow, Blanket, Clothing, Lotion, Lip Balm ú Boppy

ú Aroma Therapy

ú Garden Kneeler

ú Inflatable Pillow ú Massage Oil ú Pillow

6. Hospital items you would like to use: They provide toothbrush, lotion, soap, shampoos, pads, panties and a

peri-bottle. You may wish to bring your own nightgown, slippers, bra, socks and baby clothes.

7. If you have any preference for the following please circle it:

Ø MEDICATIONS (please circle)

NONE

As little as possible

As much as possible

Ø EPIDURAL

Ø MIRROR FOR SEEING BIRTH

Ø EPISIOTOMY or NO EPISIOTOMY

Ø BABY PLACED ON TUMMY IMMEDIATELY AFTER BIRTH/KANGAROO CARE

Ø BABY TO BE WASHED BEFORE PLACED IN YOUR ARMS

Ø SUPPORT PERSON TO HOLD BABY

Ø PRIVATE TIME WITH YOUR BABY AND FAMILY

Ø FOOD/DRINK FROM HOME TO CELEBRATE (For example: cake, wine, etc.)

Ø FAMILY MEMBERS TO GIVE BABY FIRST BATH

Ø MOM OR SUPPORT PERSON TO CUT UMBILICAL CORD

Ø BABY IN ROOM WITH MOM -

As little as possible

As much as possible

Ø BREAST FEEDING BABY AS SOON AS POSSIBLE AFTER BIRTH

Labor And Birth Plan

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