Your Birth Plan printable pdf download

Your Birth Plan

This birth plan is designed to help you have the best

General Information

labor experience possible during your child’s grand

Name: ______________________________________________

entrance into the outside world.

Prefer to be called: _ ___________________________________

Partner’s Name: ______________________________________

Labor Induction/Augmentation

Email Address: _______________________________________

If I go past my due date and there are no health risks

for me or my baby, I would prefer:

Due Date: ___________________________________________

Not to be induced

Name of Health Care Provider: __________________________

To be induced

Doula Name: ________________________________________

I would prefer trying the following induction methods

Anesthesia/Pain Medication

(choose any of the following):

Breast stimulation

I would prefer to labor without pain medication. I will ask if I

would like something for pain. Please do not ask me.

Essential oils

I would like the medication Stadol before trying an epidural.

Walking

I would like an epidural.

Sexual intercourse

Pitocin

Environment/Comfort and Relaxation Aids

Preparation

Choose any of the following:

I would like the following individuals to be present during

I would like to wear my contacts lenses if possible.

labor: ____________________________________________

I would like to wear my own clothes in labor.

_________________________________________________

I would like to wear my sports bra.

I would like the following individuals to be present during

I would prefer to be able to eat and drink

the actual birth: ___________________________________

during labor.

_________________________________________________

I would prefer no IV unless absolutely necessary.

I would prefer dim lighting.

If I need an IV, I would like to use a saline lock.

I would like music therapy using the iPod docking station/

CD player.

Monitoring

I would like to use essential oils (aromatherapy).

I would prefer intermittent fetal monitoring as

I would like the ceiling fan on at all times.

long as there is no fetal distress.

I would like to use the Jacuzzi tubs with pillows starting at

I would prefer to be monitored by the underwater

four centimeters dilated.

Doppler while in the Jacuzzi.

I would like to use a rice heating pad for comfort.

I would prefer to walk around. Mobility is

I would like to use massage aids.

important to me.

I would like a massage by a massage therapist

I would prefer continuous fetal monitoring.

(by request only).

601 E. Altamonte Drive, Altamonte Springs, FL 32701 |

Birth Coordinator (407) 303-5405

Your Birth Plan

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