BIRTH PLAN

Name: Emergency Contact:

Direct questions to: Number:

BEFORE BIRTH DURING DELIVERY

Who will be with you Comfort measures you want to take Birth positions you want to try/use
Partner, Name: Low lights

Doula, Name: Essential oils and diffuser Prefer during delivery

Photographer, Name: Music Episiotomy Tearing

Who will catch the baby

Equipment Movement Doctor Partner You

Birth ball Sheet for Pulling/Rebozo Walking the halls Immediately after delivery
Water Squat Bar Moving around the room Skin to Skin

Tub Take baby to warmer to clean them up

Clothing Hydration
Hospital gown Own clothing IV placement Continuous fluids NEWBORN CARE
Questions during contractions Eating and drinking Cord cutting
Immediately

Delayed, if so how long:

Vitamin K
VAGINAL VS. C-SECTION Administered immediately

Delivery preference Type of anesthesia you prefer Delayed for the first hour

Erythromycin
When you want the cord clamped Who you want with you in the OR Administered immediately

Delayed for the first hour

If you want a clear drape, or if you’d Who you want to stay with baby, if Hep B
prefer one you can’t see through baby needs to go to the NICU
Administered immediately

Delayed for the first hour

Golden hour
DURING LABOR
Have baby skin to skin for first hour
Comfort measures you want to take Eating or drinking Have breastfeeding help during this time
Walking halls Shower or tub Brought food to eat and drink
Feeding preferences
Moving around the room Squat bar Ice chips/slushies from the hospital
Breast Bottle
Birth ball or peanut ball Hydration
Rooming-in or nursery
IV placement Continuous fluids
Have baby leave the room for examinations
Induction/augmentation options and/or so you can sleep
Pain medication you want, or don’t
you want or dont want want, suggested Keep baby in the room
Pitocin AROM Vacuum Forceps
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