Birth Plan/preference List (Page 2 of 2) in pdf

6. Who will provide the following?

• Ride to the hospital: _____________________________________________________________________

• Support during labor: ____________________________________________________________________

• Ride home from the hospital: _____________________________________________________________

7. We encourage you to consider breastfeeding your baby and to attend the Preparation for

Breastfeeding class. If you prefer to bottle feed, we support your preference.

Your Preference: ❑ Breastfeeding ❑ Bottle feeding ❑ Both

8. If you have a baby boy, you need to decide if he will have a circumcision. Please read the section on

Circumcision in the Pregnancy Guide and let us know your choice.

Your Preference: ❑ Yes ❑ No

9. Do you have religious, cultural, or spiritual needs that we should know about?

Notes: __________________________________________________________________________________

10. It is a good idea to start thinking about your options for family planning after delivery. Please review

the section on Birth Control Methods in the Pregnancy Guide.

If you are considering a tubal ligation (permanent birth control), you must sign your consent form

before you go into labor.

Notes: __________________________________________________________________________________

11. Any other requests?

Requests: _____________________________________________________________________________

______________________________________________________________________________________

We have every intention of honoring all of your requests. In some situations, it maybe necessary to

change your birth plan for your health or your baby’s health.

Birth Plan/preference List Page 2