My Birth Plan
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1
2Patient Name: _______________________________________________________________________
Hospital Stay Preference Information
My birth
Labor Medication:
plan
My feelings and wishes about medication: __________________________________________
________________________________________________________________________________
________________________________________________________________________________
o I am open to the use of pain medication
o I am not open to the use of pain medication
o Please do not ask me about the use of pain medication
o Do not offer me pain medication unless I say my code word: __________________________
o I would like an epidural
Immediately After Delivery:
My feelings and wishes after delivery: ________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
o I wish to have skin-to-skin contact with my baby
o Please delay cord clamping and cutting until pulsating ceases
o I would like my baby to remain with me according to my wishes
o I wish to breastfeed exclusively
o I wish to breastfeed, but formula supplementation is acceptable
o I wish to formula feed
o I do not want my baby to be given a pacifier
o I would like to meet with a lactation consultant
o I would like my baby circumcised
o I do not want my baby circumcised
o I have reviewed and discussed the above requests with my healthcare provider.
Parent(s) Signature: ___________________________________________________
Date: ___________________________
200-46490-0017 Rev. 12/10
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