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Birth Planner for Home Birth or Hospital

Fill in the check boxes before or after printing.

Your name:

Your Spouse/friend’s name:

Due Date:

ALLERGIES TO MEDICATIONS:
Name of doctor/midwife:

Name of midwife/doula or support person (other than spouse):

PREPARATION: Do you want…

An enema?
Yes
No

Shave/prep?
Yes
No

Private room?
Yes
No

Hospital gown?
Yes
No

Heparin/Saline Lock (Most hospitals require this as access to a vein should an emergency occur)
Yes
No

Freedom to bring/play own music?
Yes
No

Your own clothing?
Yes
No

Intravenous drip in labor?
Yes
No

Consent to be a teaching patient (students and staff may be present at any time)?
Yes
No

LABOR: Do you want…

Food/fluids on request throughout labor?
Yes
No

Not to be offered pain medications during labor/delivery?
Yes
No

Not to be offered pain medications during labor/delivery, but would like to keep the option open if I request it?
Yes
No

Pain medications as soon as possible?
Yes
No

Freedom to shower or labor in a tub?
Yes
No

External electronic fetal monitoring for test strip only?
Yes
No

Internal electronic monitoring (this requires rupture of membranes and attachment of electrode to baby’s scalp in utero.)?
Yes
No

Monitoring baby’s heart tones by hand doppler?
Yes
No

One-to-one nursing support and care during labor?
Yes
No

Freedom to choose positions and activity in labor (walking, sitting, squatting, lying on side, etc.)?
Yes
No

Examination for specific medical indication only?
Yes
No

Lying in bed during labor?
Yes
No

Full information on risks and benefits of each suggested medical procedure?
Yes
No

“Routine” artificial rupture of membranes?
Yes
No

Artificial hormone (Pictocin typically) to boost contractions or induce labor?
Yes
No

Analgesia or anesthesia for pain in labor?
Yes
No

Spouse/chosen person present from entry to hospital through labor?
Yes
No

Spouse/chosen person present during any medical procedure?
Yes
No

Admission papers complete in mother’s room?
Yes
No

BIRTH: Do you want…

Episiotomy?
Yes
No

Freedom of position during birth?
Yes
No

Minimal number of staff in room?
Yes
No

Freedom to touch baby during delivery?
Yes
No

Father assisting with actual delivery by hand?
Yes
No

Hot compresses and massage to help the perineum stretch?
Yes
No

Father cutting the cord?
Yes
No

Freedom to take photographs/videotape throughout?
Yes
No

Midwife/doula attending?
Yes
No

Female, rather than male, physician?
Yes
No

Delivery room warmed for birth above 70°?
Yes
No

Dimmed lights for actual birth?
Yes
No

No mask worn by father during birth (to enhance contact with baby)?
Yes
No

Baby allowed to take first breaths unassisted (no immediate suctioning, etc.)?
Yes
No

Late cord clamping (after pulsating stops)?
Yes
No

Skin-to-skin contact with baby immediately after birth for mother and father?
Yes
No

Baby cleaned before presenting to mother?
Yes
No

“Routine” artificial hormone injection after delivery to contract uterus and expel placenta?
Yes
No

Baby on breast to stimulate the uterus contractions and expel placenta?
Yes
No

Electronic warmer for baby?
Yes
No

Erythromycin delayed at least one hour?
Yes
No

Mirror placed for birth?
Yes
No

Freedom to touch baby during delivery?
Yes
No

Vernix (creamy secretion on skin at birth) left on?
Yes
No

Siblings present for birth?
Yes
No

Vitamin K shot to baby?
Yes
No

Measuring, weighing to be done in room?
Yes
No

Father to accompany baby to be weighed and measured?
Yes
No

RECOVERY: Do you want…

Baby remains in nursery, except for feedings?
Yes
No

Baby remains with mother at all times (nights included)?
Yes
No

Visitors of choice in mother’s room at any time of day?
Yes
No

Breast feeding on demand from birth?
Yes
No

Bottle feeding only?
Yes
No

Both a combination of breast and bottle feeding are fine?
Yes
No

Sugar water between feedings?
Yes
No

A note to be placed on my door asking for visitors to knock first?
Yes
No

Freedom of movement for mother after birth (shower, etc.)?
Yes
No

Circumcision?
Yes
No

Both a combination of breast and bottle feeding are fine?
Yes
No

Circumcision delayed until 8th day?
Yes
No

Early discharge from hospital as soon as baby and mother are stable (hospital personnel availble for support by phone)?
Yes
No

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