Birth Plan Worksheet PDF Details

After you have created your birth plan , the next step is to take it to your prenatal appointments. Bring a copy of your birth plan with you to each appointment, so that your care provider can get an idea of what kind of birth you are hoping for. You may also want to bring a copy of the worksheet to help you keep track of what information your care provider provides about your pregnancy and delivery. The worksheet will also help ensure that all of your questions are answered before labor begins. The goal of this blog post is to provide you with a copy of the prenatal appointment Birth Plan Worksheet, in case you would like to use it during your own prenatal appointments.

Here is some facts that will help you identify how much time it requires to finalize the birth plan worksheet.

QuestionAnswer
Form NameBirth Plan Worksheet
Form Length2 pages
Fillable?Yes
Fillable fields114
Avg. time to fill out23 min 22 sec
Other namesbirth plan checklist, how to write a birth plan, birth plan template, birth plans

Form Preview Example

My Birth Plan

Due Date:

Your Name:

Spouse/Partner's Name:

Others to be Present During Labor and Birth:

Childbirth Preparation/Education Method:

Doula/Birth Partner:

Pediatrician:

I understand that this document reflects my birth preferences, it is not a medical document, and that depending on the situation occurring, it may need to be altered for the safety of myself and my child. Ask your provider to review this with you and take it with you to the hospital when your labor begins.

My delivery is planned as:

Vaginal delivery

C-section

VBAC

During labor, I prefer:

Music played

Dimmed lights

Quiet room

As few interruptions

As few vaginal exams

Peanut ball

My partner to be present at all times Hydrate with clear liquids & ice chips

I am planning to collect Cord Blood

No Yes

Donation

Tissue

Blood

Company:

For pain relief, I prefer:

IV medications

Epidural

Only what I request at that time

Whatever is suggested

Nothing, please do not suggest epidural Comments:

During the 1st stage of labor, I prefer:

Standing

Laying down

Walking around

Comments:

For fetal monitoring, I prefer:

Continuous

Intermittent

I understand that if I am to be induced or need Pitocin started, continuous monitoring must be implemented.

If I need labor augmentation, I prefer:

Pitocin

Artificial rupture of membranes

Both

Comments:

For delivery position, I prefer:

Laying on back (regular position)

Laying on side

Hands and knees

Using birth bar

Squat

Comments:

I understand that an epidural or inability to monitor the baby appropriately may require a different position than I prefer.

As the baby delivers, I prefer to:

Be directed on pushing

Push spontaneously

Use a mirror to see the baby crown

Let the epidural wear off while pushing

Have a full dose of epidural

Touch the head as it crowns

Use mineral oil/lubricants

If I require assistance at delivery, I prefer:

Episiotomy

Operative delivery with forceps/vacuum Cesarean section

No preference

Immediately after delivery, I prefer:

Delayed cord clamping

Skin to skin

My partner to cut the cord

Baby to go to the warmer

Other:

Comments:

I understand that at Sibley, delayed cord clamping and skin to skin immediately after birth are standard. However, implementation is deemed by the pediatrician/doctors depending on the condition of the baby. Likewise, for cutting the cord, my partner may not be able to if the baby must be evaluated immediately.

I would like to hold baby:

Immediately after delivery

After suctioning

After weighing/measurements

After being wiped clean and swaddled

Comments:

I prefer baby's medical exams/procedures:

Given in my presence

Given in my partner's presence

Comments:

I prefer my baby's first bath be given:

In my presence

In my partner's presence

By me

By my partner

Comments:

For the placenta, I prefer:

To look at it before it is discarded

To take it home with me

To have it discarded

I understand that the placenta may need to be sent to the lab if the provider deems it necessary.

If a C-section is necessary, I prefer:

All other options have been exhausted

Explanation of risks/benefits and indication for the procedure

My partner to hold the baby ASAP

Breastfeed in the recovery room

I understand that my partner will be allowed in the operating room as long as there are no complications. I understand that delayed cord clamping is implemented standardly during C-section, unless the pediatrician needs to assess the baby immediately.

I would like to breastfeed:

As soon as possible after delivery

Later after resting

I prefer to bottle feed

Comments:

I would prefer the baby not to receive:

Vitamin K shot

Antibiotic eye ointment/drops

Formula

A pacifier

Comments:

I would like to feed baby:

Only with breastmilk

Only with formula

On demand

On schedule

With the help of a lactation consultant

Comments:

If we have a boy, circumcision should:

Be performed

Not be performed

Comments:

Signature:Date:

How to Edit Birth Plan Worksheet Online for Free

Completing documents with our PDF editor is simpler in comparison with most things. To modify birth plan template the file, there is little you need to do - simply adhere to the steps listed below:

Step 1: Hit the button "Get form here" to access it.

Step 2: When you enter our birth plan template editing page, you will see each of the options you may undertake with regards to your document in the top menu.

Fill in the next parts to create the template:

birthplan gaps to complete

Fill out the Music played Dimmed lights Quiet, During the 1st stage of labor, Standing Laying down Walking around, Comments:, For fetal monitoring, Continuous Intermittent, I understand that if I am to be, Pitocin Artificial rupture of, Comments:, IV medications Epidural Only what, Comments:, For delivery position, Laying on back (regular position), Comments:, and I understand that an epidural or areas with any information that may be requested by the software.

Music played Dimmed lights Quiet, During the 1st stage of labor, Standing Laying down Walking around, Comments:, For fetal monitoring, Continuous Intermittent, I understand that if I am to be, Pitocin Artificial rupture of, Comments:, IV medications Epidural Only what, Comments:, For delivery position, Laying on back (regular position), Comments:, and I understand that an epidural or in birthplan

The application will request you to put down certain important particulars to easily complete the area Be directed on pushing Push.

step 3 to finishing birthplan

Indicate the rights and obligations of the sides in the field If I require assistance at, Episiotomy Operative delivery with, Immediately after delivery, Delayed cord clamping Skin to skin, I understand that at Sibley, Comments:, For the placenta, To look at it before it is, I understand that the placenta may, If a C-section is necessary, All other options have been, I understand that my partner will, I would like to breastfeed:, As soon as possible after delivery, and Comments:.

birthplan If I require assistance at, Episiotomy Operative delivery with, Immediately after delivery, Delayed cord clamping Skin to skin, I understand that at Sibley, Comments:, For the placenta, To look at it before it is, I understand that the placenta may, If a C-section is necessary, All other options have been, I understand that my partner will, I would like to breastfeed:, As soon as possible after delivery, and Comments: fields to fill

Finish by checking these fields and filling out the required data: I prefer baby's medical, Given in my presence Given in my, Comments:, I prefer my baby's first bath be, In my presence In my partner's, Comments:, Vitamin K shot Antibiotic eye, Comments:, I would like to feed baby:, Only with breastmilk Only with, Comments:, If we have a boy, Be performed Not be performed, Comments:, and Signature:.

Entering details in birthplan part 5

Step 3: Choose the "Done" button. Finally, you may export your PDF document - download it to your electronic device or send it by means of email.

Step 4: Ensure that you keep away from possible worries by creating no less than 2 copies of your file.

Watch Birth Plan Worksheet Video Instruction

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