Printable Birthing Plan 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 Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesbirth plan checklist, birth plan generator, birth plans, how to write a birth plan

Form Preview Example

BIRTH PLAN WORKSHEET

NAME: ______________________________________________________________________

ATTENDANTS

I'd like the following people to be present during labor and/or birth:

Partner: ___________________________________________________________

Friend/s: __________________________________________________________

Relative/s: _________________________________________________________

Doula: ____________________________________________________________

Children: __________________________________________________________

AMENITIES I'd like to:

bring music dim the lights

wear my own clothes during labor and delivery take pictures and/or video during labor and delivery

HOSPITAL ADMISSION & PROCEDURES

I'd like the option of returning home if I'm not in active labor.

Once I'm admitted, I'd like:

my partner to be allowed to stay with me at all times

only my practitioner, nurse, and guests to be present (i.e., no residents, medical students, or other hospital personnel)

to wear my contact lenses, as long as I don't need a c-section to eat if I wish to

to try to stay hydrated by drinking clear fluids instead of having an IV to have a heparin or saline lock

to walk and move around as I choose

OTHER INTERVENTIONS

As long as the baby and I are doing fine, I'd like to:

have intermittent rather than continuous electronic fetal monitoring be allowed to progress free of stringent time limits and have my labor augmented only if necessary

BabyCenter Birth Plan worksheet page 2

LABOR PROPS

If available, I'd like to try a: birthing stool birthing chair squatting bar birthing pool/tub

I'd like to bring the following equipment with me: birthing stool

beanbag chair birthing pool/tub

other: ____________________________________________________________

PAIN RELIEF

I'd like to try the following pain-management techniques: acupressure

bath/shower

breathing techniques/distraction hot/cold therapy self-hypnosis

massage medication

other: ____________________________________________________________

Please don't offer me pain medication. I'll request it if I need it.

If I decide I want medicinal pain relief, I'd prefer:

regional analgesia (an epidural and/or spinal block) systemic medication

PUSHING

When it's time to push, I'd like to: do so instinctively

be coached on when to push and for how long

be allowed to progress free of stringent time limits as long as my baby and I are doing fine

I'd like to try the following positions for pushing (and birth): semi-reclining

side-lying position squatting hands and knees

whatever feels right at the time

BabyCenter Birth Plan worksheet page 3

VAGINAL BIRTH During delivery, I'd like:

to view the birth using a mirror

to touch my baby's head as it crowns the room to be as quiet as possible to give birth without an episiotomy my partner to help "catch" our baby

After birth, I'd like:

to hold my baby right away, putting off any procedures that aren't urgent to breastfeed as soon as possible

not to get oxytocin (Pitocin) after I deliver the placenta unless it's necessary

to wait until the umbilical cord stops pulsating before it's clamped and cut my partner to cut the umbilical cord

C-SECTION

If I have a c-section, I'd like:

my partner present at all times during the operation

the screen lowered a bit so I can see my baby being delivered

the baby to be given to my partner as soon as he's dried, if appropriate to breastfeed my baby in the recovery room

CORD BLOOD BANKING

I'm planning to:

donate cord blood to a public bank bank cord blood privately neither

POSTPARTUM After delivery, I'd like:

all newborn procedures to take place in my presence

my partner to stay with the baby at all times if I can't be there to stay in a private room

to have a cot provided for my partner

I'd like:

24-hour rooming-in with my baby

my baby to room-in with me only when I'm awake my baby brought to me for feedings only

to make my decision later depending on how I'm feeling

my other children brought in to see me and meet the new baby as soon as possible after the birth.

BabyCenter Birth Plan worksheet page 4

FEEDING ISSUES

I plan to:

breastfeed exclusively

combine breastfeeding and formula-feeding formula-feed exclusively

Do NOT offer my baby: formula sugar water a pacifier

CIRCUMCISION

If my baby's a boy:

I want him to be circumcised at the hospital

I'll have him circumcised later

I don't want him circumcised

DISCHARGE I'd like to:

be discharged from the hospital with my baby as soon as possible stay at the hospital as long as possible

wait and see how I feel before deciding about the timing of hospital discharge

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