Birth Plan Worksheet

A birth plan worksheet is a practical tool that outlines and clarifies your preferences for labor and delivery.

Early/First Stage Labor

Atmosphere and Environment

I would like to dim the light

I would like to bring my music

I would like to wear my own clothing

I would prefer to wear my contact lenses/glasses

Coach/partner only desired attendees other than medical staff

I want my labor and delivery photographed/video recorded

Other _______________________________________________

Mobility

choose one:

Unlimited freedom to move (walking, bathroom, rocking chair, fitness ball, etc.)

Mobility is not important to me

I.V.

I.V. insertion is acceptable at any point

I.V. placement should be attempted only if dehydration occurs

Hydration

No restrictions

Clear fluids

Ice chips

IV

Monitoring

choose one:

Intermittent monitoring (Fetoscope, Doppler, etc.)

Continuous monitoring (External leads, internal monitoring)

No monitoring except in emergency situations

Catheritization

I would like to avoid catheterization unless it is absolutely necessary

Pain Relief Options

I would like to try the following pain-management natural techniques:

Hot or cold compresses

Positioning

Water therapy (bath, whirlpool, shower)

Massage

Accupressure

Hypnotherapy

Breathing techniques/distraction

Pain Relief Offer

Do not offer; I will ask if I desire it

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

Systemic medication

Regional analgesia (an epidural and/or spinal block)

Labor Induction

No induction

Stripping of membranes

Cervical gel

Pitocin

Cytotec

Rupturing of the amniotic sac

I prefer my amniotic sac be allowed to rupture on its own

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