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Personalized Birth Planner

Personalized Birth Planner

A birth plan will help your care provider fully understand your preferences for certain procedures during labor and delivery. It is separated into three pages for easy loading. Just hit the "Next" button at the bottom of each page to continue. When you are finished, you will be able to print out your personalized birth plan in letter format to give to your care provider. We have provide a standard letter introduction. If you would like to make it more personal, just delete what is there and change it as you wish. We have also provided "Other" boxes, so that you can personalize it even more.

Your Full Name
Name of Your Doctor, Midwife

Name of Birth Site (where you will deliver your baby)

Name of Your Labor Partner(s) (hospitals usually allow two)


Your due date

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Letter Introduction
The following is a detailed description of my preferencesfor procedures during labor and delivery. I hope thattogether we can make my labor and delivery as smooth aspossible.

Before Labor

I would like to
stay at home as long as possible
come into hospital and get settled in right away

Labor Room

I would like to wear My own clothes

I would like to walk, and move around during labor.

I would like to drink fluids, ice chips, light snacks

I would like the environment to be kept as quiet as possible.

I would like the lights in the room to dimmed during my labor, and delivery.

I would like to wear contact lenses or glasses at all times when conscious.

Other

Relaxation Methods

Massages
Bath tub
Whirlpool
Shower
Acupuncture
Aromatherapy

Other

Labor Room Procedures

I would like to have an IV

I would like to have an Enema

Other:

Monitoring

I would like to have continuous fetal monitoring

I would like to have internal monitor

Other

Labor Augmentation/Induction

I would like to have the amniotic membrane ruptured artificially.

I would like to have the amniotic membrane ruptured before other methods are used to augment labor

Before pitocin is administered, I would like to try changing position and other natural methods (walking, nipple stimulation).

Other

Pain Relief

I would like to have pain reliever medication

I would like to have an epidural

I would like to have a low dose epidural

I would like to try hypnobirthing

I would not like to use any medication

Other

Ceserean

I would like to avoid having a ceserean

I would like to be fully informed and particiapte in the decision-making process

I would like to have the screen lowered I would like to have the baby given to
Myself
My husband
My Partner
The doctor/midwife
The nurse

Other

Third Stage - Pushing Stage

I would like to have an episotomy

I would like to have perineal massage

I would like to have local anesthetic

I would like to have someone support my legs during the pushing stage

I would like the room to be as quiet as possible

I would like the baby to be placed on my stomach

Other

After Delivery

I would like to have the baby bathed and weighed in my presence

I would like to have a private room, if available

I would like to have a roommate, if possible

I would lke the baby to room in with me

Other

Feeding

I would like to begin nursing right after birth

I would not like any bottles to be given to my baby (including glucose water)

I would like the baby to be given a pacifier

I would like to bottle-feed my baby

I like to meet with a lactation consultant

Other

Primary Care Provider

Person Performing the first exam of your baby
Name of Care Provider

Circumsision

I would like my baby to be circumsized

I would like the circumsision to be performed in the hospital

I would like the circumsision to be performed before we check out of the hospital

other

Miscellaneous

I would like to have photographs taken during labor and birth

I would like some one videotape the labor and/or the birth.

I would like my other child/ren to be able to visit me and the baby in the hospital

I would like students interns residents or non-essential personnel be present during my labor or the birth

other

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