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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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