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Personalized Birth Planner

A birth plan will help your care provider fully understand your preferences for certain procedures during labor and delivery.

Introduction  

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)
Name of Baby's Care Provider
Your due date
Letter To Your Doctor
Before Labor  
When would you like to go to the hospital? Stay at home as long as possible
Come into hospital and get settled in right away
I have an appointment.
During Labor  
Labor Room Details 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.

Relaxation Methods

Massages
Bath tub
Whirlpool
Shower
Acupuncture
Aromatherapy
Guided Imagery

Labor Room Procedures

 

I would like to have an IV
I would like to have an Enema
Monitoring I would like to have continuous fetal monitoring
I would like to have internal monitor
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).
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
Delivery  

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

Vaginal Delivery

 

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
After Delivery  

Details

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 like the baby to room in with me
I would like to have the baby given to Myself
My husband
My Partner
The doctor/midwife
The nurse

What Are Your Feeding Prefrences?

 

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

Circumsision Details

 

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

Miscellaneous Details

 

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 my other child(ren) to be in the room during the delivery
I would like students interns residents or non-essential personnel be present during my labor or the birth



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