MY BIRTHPLAN By: Angeline Manoso BSN 2-16
After delivery
Name:
Baby's due date:
Equipments/supplies: for me and my baby
Labor and delivery budget expenses:
Insurance available:
Medical team's names and contact/information details:
Doctor:
Midwife:
Doula:
Pediatrician:
Hospital/birthing center's address:
Name of the driver and vehicles to be used:
Birth partner's name and contact details:
Blood supply, type and address:
Important medical issues:
Labor
During labor, I prefer to be...
_standing up _lying down _walking around
Other:
When it comes to pain management, I would prefer...
_not to use any _standard epidural _walking epidural
_massage _breathing techniques _cold therapy _warm
compress _warm bath _positioning
Other:
I'd like fetal monitoring to be: _continuous
_intermittent _with Doppler only
I'd like to hold my baby skin-to-skin immediately after delivery:
_Yes _No
Labor environment I want to delay newborn procedures( such as bathing and
I would like to: _limit interruptions as much as possible measuring) for the first hour so I can feed and bond with my baby:
_minimize hospital staff as much as possible _an all female
_Yes _No
staff _limit vaginal exams _walk and move around during
labor _play music _Limit noise _my partner to film And/Or
I want all the procedures and all the medication explained to me
take pictures
before they are carried out: _Yes _No
Delivery I'd prefer my baby to be kept with me... _at all times _during the
During delivery, I prefer to be... day _only when I am awake
_squatting _standing _semi-reclining Other:
Other:
When it comes to feeding my baby, I prefer to... _Breastfeed
I would like my birth partner with me in the delivery room:
_Breastfeed, with the help of a lactation consultant _use formula
_Yes _No
I would like an episiotomy...
_rather than risk a potential tear _not performed, at any
cost Newborn care
Other: Cord cutting _immediately _delayed. If so how long
Vitamin K _administered immediately _delayed for the first hour
Type of anesthesia (in the case of a cesarean): Erythromycin _administered immediately _delayed for the first
hour
Should I need a cesarean, I would like... Hep B _administered immediately _delayed for the first hour
_to stay conscious _My partner to be with me the entire
time
After gave birth
_to hold my baby right after delivery
I'd prefer to have family planning: _yes _no
Other: Kind of birth control I want is to take/have:
_Use birthing stool _pills _IUD _shot _implant _patch _vaginal ring _barrier methods
_Have a mirror available to see my baby being born