Birth Plan Checklist

I recommend creating a birth plan for the hospital staff that is short & concise, covering which interventions you do not want. But, I also recommend creating another birth plan for yourself, your husband and doula covering more of the finer details in how you envision your birth to unfold and all the ways you want to be supported. You only have to submit what you believe is important. It may be easier to view in desktop.

Name

Birth Support Person #1

Birth Support Person #2

Vistors who are welcome in your birth space

Describe the birth are you planning.

Envision your dream birth, believing everything went perfectly. It can be anywhere in the world, any setting, any details. You do not have to share here, but reflect how components of your dream birth can be made real.

Think of times in your life when you felt most empowered. Sharing them here is optional. What would make your birth empowering?

What are some affirmations, words, statements, scriptures that empower you to be courageous?

What are some words, statements, affirmations, scriptures, that give you peace & hope?

What songs relax you and calm your nerves, knowing everything is going to be alright?

What songs empower you to feel like you can do anything and that you are a phenomenal person.

What essential oils or scents are your favorite? Are there any scents that you really don't like?

What are some of your favorite snacks for energy? protein? Do you have any favorite herbal teas?

Do you want your labor & birth filmed or photographed? Any certain pictures/scenes you hope to get taken?

Names some things that bring you comfort. What is most relaxing to you?

Of the comfort measures you clicked above, what are your top 3?

Labor Induction

I do not want to be induced. I want to let labor naturally progress and facilitate a safe, loving, nourished environment for optimal hormones to stimulate contractions

Natural Induction/Stimulation only

I do not want Pitocin

Pitocin only if labor has stalled after an epidural

Pain Meds/Epidural

Please do not ask or discuss my pain levels

I do not want to be offered pain medication

I do not want an epidural

Please do not suggest an epidural

If I ask for an epidural please try to offer me other comfort measures, positionings, and affirmations first.

If I want an epidural I would like a walking epidural and continue to instinctively move so baby can get in optimal position

If I get a standard epidural I want a peanut ball for pelvic positioning and to try different positions in bed at my request

Vaginal Exams

I do not wish to be checked unless absolutely necessary

I like to know what progress I am making

Episiotomy

I would rather tear naturally

Only as a last resort

I do not want local anathesia

I do not want stitches for minor tearing

Warm perinneal compresses first

Fetal Monitoring

Intermittent

Continuous

With a doppler so I have freedom of movement

Check any preferences that apply to you:

I would love for my husband or myself to catch our baby

I want delayed cord clamping of atleast 5 minutes when cord is white and limp

My husband will cut the cord

I decline Routing Pitocin after delivery

I would like to observe my placenta

I would like to take my placenta home

I would like my baby to do the 'breast crawl' and initiate breastfeeding

I would like my baby to breastfeed right away

I prefer to be cared for & delivered by women only

I do not want medical students or students midwives present

If I feel naseous or woozy, I would like to smell peppermint essential oil

I would like my waters to break naturally instead of AROM- artificial rupture of membranes. I believe the amniotic sac cushions baby, prevents infection, and prevents cord prolapse

I want to be able to move freely throughout labor and find the best positions that work for me & for how I want to give birth.

If possible, dim lighting through labor, birth, and after baby is born.

I plan to breastfeed my baby, please do not give my baby formula without my consent.

I want to touch my baby's head as they are crowning

I plan to eat & drink during labor as desired to keep my energy up so my natural hormone, muscles, mind, and overall strength is nourished and not hindered.

If GBS status is unknown, I decline antibiotics and would like to follow the CDC guidelines for intrapartum unknown GBS – no antibiotic risk factors are present (delivery before 37 weeks, ROM > 18 hours, temperature >100.4 F)

I want delayed cord clamping of atleast 5 minutes, until cord is white, limp, and done pulsating. I do not want to be rushed to cut the cord. I want to make sure my baby received all their stem cells and blood volume. Childhood anemia is on the rise and related to early cord clamping.

I have researched vaccines and both sides of the controversy and am making informed decisions that are best for my baby. (vaccinetruth.org)

I decline the newborn Hepatitis B vaccination

I decline the Vit K shot

Immediate Skin to Skin

The first hour after birth is very important to me for bonding with my baby and feeling warm, safe, and as undisturbed as possible to ensure natural hormones are not distrupted for a better start at breastfeeding and for safe expulsion of my placenta.

I want to birth my placenta naturally without cord traction

I decline newborn eye antibiotic ointment, Erythromycin.

If having a boy, I have researched circumcision and watched a video of newborn circumcision and am making an informed decision that is best for my baby (yourwholebaby.org)

I want to delay newborn evaluations after the first hour, or that they are done while baby is skin to skin.

I wish to delay newborn bathing & rub all baby's vernix into their skin

I do not want a hat on my newborn as I believe smelling my newborns' head increases my oxytocin

I do not want my baby to be swaddled or changed by others besides my husband & I

I would like to see a licensed lactation consultant

I wish newborn exams to be performed in our room or have my husband go with our baby

I request early discharge if possible

I know how to properly install the infant car seat and secure my baby

Add here any birth preferences you have that are not covered in this form.

Bearing Precious Seed LLC

Birth & Postpartum Services (BPS)

Birth Plan Checklist

Thank you for submitting!