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Birth Plan Worksheet
Decide on what you want from your birth experience. This worksheet will get you started on creating a customized birth plan to ensure your care provider is aware of your wishes.
A Labor Birth Plan Worksheet
1. I would like to give birth:
in a birthing room
in a delivery room (more surgical facilities)
in the shower
2. In my birthing room, the following is important to me:
Soft music playing
Wearing my own clothes during delivery
3. I would like to have the following people present at the birth:
4. In preparation for my delivery, I would prefer:
to use/ to not use an enema
to be/to not be induced if I go past my due date
5. If inducing labor, I would prefer these methods:
Breaking the membrane
6. During the first stage of labor:
I would / would not prefer to remain with my partner during labor or delivery
I would like to eat or drink during labor
Give me pain medication only if I ask for it/if the pain causes me too much discomfort
I would prefer not to undergo internal exams unless medically necessary for the health of me or my baby.
7. Ways I would like to manage the pain:
8. Second stage of labor:
I would prefer not have an episiotomy, even if it means tearing vaginal tissue
I would prefer having an episiotomy if there is a possibility of tissue tearing
Unless it’s medically necessary, I would prefer not having an episiotomy offered to me
9. I prefer to give birth in the following position:
Lying on my side
Hands and knees
10. During my birth:
If it’s necessary to extract the baby, use either forceps or a vacuum
I would like a mirror available so that I might see my baby’s head
I would like to touch my vaginal area as my baby’s head crowns
11. After delivery:
I wish to cut the umbilical cord myself
I wish to have umbilical cord blood preserved
I would like a private room
If my newborn leaves my presence, I would like my partner to attend to her
Cesarean Section Birth Plan
When writing your cesarean birth plan, you can choose whether to elect a c-section ahead of time, who you want in the room with you and whether you want any medical students in the room with you.
Midwife Birth Plan
Decide whether you want to have a water birth or to stay in the bedroom. You can choose to invite your partner, parents, relatives and friends.
Interactive Birth Plans
An interactive birth plan will provide you with a checklist of possible options you may want to consider and speak with your doctor about. Once you have discussed the options, you then fill out your final birth plan and print three copies-one for your partner, one for the doctor and one for the hospital staff looking after you. You can simply use a sample birth plan as a place to start discussing options with your practitioner.
Courtesy of Moms Who Think – MomsWhoThink.com