Creating Your Birth Plan
A Printable Checklist
There are many good reasons to create a birth plan. Besides communicating your desires about your baby's birth to your health care provider, writing a birth plan helps you (and your partner) to mentally prepare for the birth. It also may help facilitate discussions with your health care providers about details that you may have overlooked. Think through each and every choice you list on your birth plan.
First Stage (Labor)
Whom will you invite to attend/witness the birth?
What are your environmental preferences (lighting, noise level, music, etc.)?
What are your film/video preferences (check one)?
- Yes, I want to record the event with video
- No just cameras
- No recording devices of any kind
What are your clothing preferences (check one)?
- A hospital gown
- My own clothing
What are your fetal monitoring preferences (check one)?
- Internal fetal monitor
- External fetal monitor
What labor position do you plan to use?
What other labor preferences do you have (check all that apply)?
- I prefer to keep my contact lenses in unless I undergo anesthesia.
- Please keep pelvic exams to a minimum.
- I want to be able to walk around and change positions as desired.
- I want to be able to drink when I'm thirsty.
- I plan to use breathing, hypnosis, massage, or other pain management techniques.
- I want a room with a tub.
- I want an enema upon being admitted.
- I want to use a birthing ball.
What are your preferences for medications and anesthesia (check one)?
- I'm planning an epidural, sedatives, tranquilizers, or narcotics.
- I want to be offered pain medications if I am obviously uncomfortable.
- I prefer to ask for them.
What are your preferences for induction and labor augmentation (check one)?
Second Stage (Birth)
- I prefer that Pitocin be used if necessary.
- I want to use natural methods, like nipple stimulation, exercise, sexual intercourse, or herbs. (Consult your physician before using any method to augment labor.)
- I want my membranes to rupture naturally.
- I would like them ruptured artificially to speed up labor.
Which birthing position do you plan to use?
Which birthing accessories do you plan to use for comfort (check all that apply)?
- Squat bar
- Birthing stool
- Birthing chair
- Beanbag chair
If labor is taking a long time, but progress is being made, what action would you prefer (check one)?
- To let things be
- Some sort of augmentation
During delivery, which would you prefer (check one)?
- To tear naturally
- To have an episiotomy
To avoid tearing and/or episiotomy, do you want compresses, massage, or position changes?
What other delivery preferences do you have (check all that apply)?
- Forceps and/or vacuum extraction should only be used if absolutely necessary
- I want to view the birth with a mirror
- I prefer to exclude medical residents or students from the birth
- I want assistance delivering the placenta
During delivery, what is your preference regarding pushing (check one)?
- I want to be told when and for how long to push
- I want to push when my body tells me to
In the event of a Cesarean birth, what are your preferences (check all that apply)?
Postpartum Baby Care
- I want my partner present
- I want to be conscious
- I want video and/or pictures taken
- I want the screen lowered (or a mirror) so I can view the birth
- I want someone to explain the surgery as it's happening
- I want one hand free to touch the baby
- I want my partner (or a specific person) to cut the cord
- I want to begin breastfeeding immediately
- Other (list)
Please check all that apply.
- My partner wants to catch the baby
- My partner wants to cut the cord
- Delay cord cutting until pulsation stops
- I want my baby to be placed on my stomach immediately for ____ minutes of uninterrupted contact
- I want to postpone newborn procedures until we've had a chance to bond
- I want either myself or my partner to be with the baby at all times
- I want to delay eye mediation, Vitamin K injection, or vaccines for a certain length of time
- Pacifiers, bottles, or sugar water may be offered to my baby
- I want to begin breastfeeding within the first hour
- If my baby is a boy, I want him circumcised
- If my baby is a boy, I do NOT want him circumcised
In the event of a medical problem with the baby, what are your preferences (check all that apply)?
- I want to begin breastfeeding as soon as possible
- I want unlimited visitation for parents
- I want to be moved with the baby, if necessary, to another hospital
After you've made all of these important decisions, discuss your birth plan with your partner (if applicable) and your health care provider, and modify it if necessary. Make copies of the final draft to take with you on delivery day, and make sure your health care provider receives a copy.