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BIRTH PREFERENCES WORKSHEET
You can never really plan your birth. How it plays out - when labor starts, how fast it goes, etc. is not in our control. So why create a birth plan? To educate yourself around the choices you DO have during your birth, and to let your birth team know exactly what you need in order to feel supported and taken care of.
Creating a personal birth plan will prepare you for your birth, allow you to become familiar with the pros and cons of each option available to you and help you create the best possible birth experience for you and your baby.
Your birth plan should be less than a page; that is not a lot of room so be sure to note what is most important to you and your family. Go over your birth plan with your care provider at around 36 weeks, and have several copies made for the day of your birth.
The following are some of the options you might consider when working on your birth plan. Once you’ve researched/reflected on your choices, you can size it down to your priorities.
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Indicates required field
Name
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First
Last
Partner (if applicable)
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First
Last
Estimated Due Date
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During labor I would like...
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To bring music
Dim the Lights
Wear my own clothing
Take pictures and/or video of the birth
What else would help you feel comfortable in your labor room?
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Would you like labor to start naturally, even if you go “post dates”?
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When thinking about induction, would you be comfortable with:
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Stripping Membranes
Prostaglandin Gels
Foley Ballon
Pitocin
Once your in labor would you like:
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To labor at home as long as possible?
The option to return home if I'm not in active labor when arriving at the hospital?
Once you are admitted to the Hospital (if choosing a hospital birth):
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I would like to have an IV
I would prefer a Saline Lock
I want to eat and drink to stay hydrated and energized
Who do you want with you in your labor room?
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Are you comfortable with having residents in attendance?
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Yes
No
As long as you and the baby are doing fine, would you like:
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To monitor the baby’s heart rate intermittently rather than using a Continuous Electronic Fetal Monitor?
To refuse the use of Internal Heart Rate Monitors unless medically necessary?
To allow labor to move at it’s own pace, free of stringent time limits?
For any discomfort during the first stage of labor (dilation) would you like to try:
Changing Positions?
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Walking
Standing
Hand and Knees
Sitting
Squatting
Equipment
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Birth Ball
Birth Tub
TENS Unit
Non-medical Comfort Techniques?
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Bath/Shower
Breathing techniques/Hypnosis
Rebozo
Massage
Hot/Cold Therapy
What are some other coping techniques you may have used in your life that you can bring into your birth? What do you do when you’re feeling sick, have a cold, or are under stress?
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How do you feel about the use of Pain Relief Medication during your birth?
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I don't want any pain relief medication.
I would like my care providers to let me know when a good time to use medication would be.
I would prefer to ask for it, only when/if I feel like I need it
I want it as soon as possible.
What if labor slows or stalls?
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I would you like to try natural means to speed it up, such as walking, eating, changing positions.
I would feel comfortable with my care provider breaking my water as a mean to speed labor up.
I would feel comfortable with the use of Pitocin.
During The Second Stageof Labor (“pushing”) would you like to try different positions, such as:
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Semi Reclining
Side Lying
Squatting
Hands and Knees
Standing
Whatever feels right at the time
When it is time to push would you like:
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To do so instinctively, bearing down when my body gives me the "urge to push"
To be coached on when to push and for how long
For the room to be as quiet as possible
During the birth would you like:
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To view the birth with a mirror
To touch your baby’s head as it crowns
For the room to be as quiet as possible
To risk a tear or birth over an intact perineum rather then an episiotomy
Your Partner to help catch the baby
If you have a Cesarean Birth would you like:
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Your partner with you at all times, even during administration of the spinal block?
To have the screen lowered a bit so you can see the birth of your baby?
Your partner to hold the baby skin to skin after the birth?
To breastfeed your baby as soon as possible
If a Cesarean Birth became necessary, how would you feel? What could you do to ensure that this birth is still a positive experience?
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After the birth would you like:
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Delayed cord clamping
To deliver placenta naturally
For your partner to cut the umbilical cord
Is there anything else you would like to add or you think I should know?
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If you have any questions about any of the options in this form feel free to write me an email or make a note to discuss them during one of our prenatal meetings.
Format:
After you have analyzed your options carefully, I will be happy to help you put them all together in a visual birth plan. Doctors and nurses love the simplicity of this format!
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