Birth Plan Checklist

A birth plan is a useful tool to let the hospital staff know exactly what you would and would not like done during the birth of your baby. Here are some ideas to help you put one together.

Environment

Home
Private birthing room
Dim lights
Soft music
Peace and quiet
Wear my own clothes
Hospital gown
Videotape labor and birth
Take pictures during labor and birth
Private phone
Other amenities: VCR, stereo, flowers

Support People Present at Birth

Partner
Relatives
Friends
Siblings
Labor assistant/Doula
No excess hospital staff
Support people present at mother's discretion and according to hospital protocol

Preparation Procedures and Labor

Free to walk and move around
Eat and drink during labor
Clear fluids and ice chips available at all times
Prefer to avoid an enema or shaving
No IV unless necessary
If so, then heparin or saline lock IV
No unnecessary examinations and very minimal vaginal examinations

Monitoring

Fetoscope
Doppler
Intermittent external fetal monitoring
Intermittent internal fetal monitoring

Pain Relief

Massage
Hot/cold packs
Hypnosis
Relaxation
Shower or bath tub
Breathing techniques
Movement (walking, swaying, rocking)
Acupressure
Acupuncture
Meditation
Epidural or spinal anesthesia
Narcotics
Sedatives and tranquilizers
None at all

Induction

Medically Induced

Pitocin
Prostaglandin gel
Amiotomy
Stripping of membranes
Cytotec
Cervadil

Self Induced

Acupuncture
Walk
Castor oil
Nipple stimulation/thumb sucking
Sexual intercourse (if bag of waters aren't broken)
Herbs

Episiotomy

Yes
No

Delivery Positions for Labor

Semi-sitting with footrests or stirrups
Side-lying
Lying prone
Squatting
Hands and knees, pelvic rock
Standing upright
Walk
Lunge

Birthing Equipment

Birthing bed
Birthing stool
Birthing chair
Birthing pool/tub
Beanbag chair
Squatting bar
Other
I would like a mirror available so I can see the baby's head crown
I would like to touch my baby's head as it crowns
I would like to have the baby placed on my stomach/chest immediately after birth
Room as quiet as possible

Pushing

Spontaneous
Directed

Extraction Devices

None unless baby's health at risk
Vacuum extraction
Forceps

Cesarean

Partner present at all times during the operation
I'd like to be conscious
Screen lowered so I can see the baby coming out
One hand free to touch the baby
Immediate contact with the baby

Placenta

Cord Blood collection
Injection of Pitocin to aid with delivery
Spontaneous
Encourage with breast stimulation, baby suckling
Manual extraction
I'd like to see it
Use of placental tissue by the hospital

Cord-cutting

Partner cuts cord
I would like to cut the cord
Neither
Other family member

Newborn Procedures

Done in my presence
Done in my partner's presence
Expanded Newborn Screening (arranged prior to delivery)

Feeding baby

Breast
Bottle
Both

Separation

No separation
Partial rooming
Nursery

Circumcision

Yes
No

Hospital Stay:

Short as possible
Long as possible