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Gynecological consultants to the
athletic department at UT Austin.

Birth Plan Guide

Title for your plan:

Birth Plan
Birth Preferences
Our wishes for Childbirth
My wishes for Childbirth
Regarding Labor and Birth

First name:

Middle name:

Last name:

Name of primary healthcare provider (if a doctor, please include 'Dr.'):

Name of Hospital/Center where you plan to deliver:

Your due date:

Coach (you might want to just write 'my husband,' or 'my coach'):

Your other support staff

How would you like to refer to your baby? (My baby, the babies, my son, etc.)

Labor

I would like to be free to walk around during labor.

I wish to be able to move around and change position at will throughout labor. [Standard practice at OGN]

I would like to be able to have fluids by mouth throughout the first stage of labor.

I will be bringing my own music to play during labor.

I would like the environment to be kept as quiet as possible.

I would like the lights in the room to be kept low during my labor.

I would prefer to keep the number of vaginal exams to a minimum. [Standard practice at OGN]

I do not want any IV fluids unless I become dehydrated.  I understand that a saline-lock IV base is required in the hospital.

I would like to wear contact lenses or glasses at all times when conscious.

Other:

Monitoring

I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby.

I do not want an internal monitor unless the baby has shown some sign of distress.

Other:

Labor Augmentation/Induction

I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring.

If labor is not progressing, I would like to have the amniotic membrane ruptured before other methods are used to augment labor.

I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation) before pitocin is administered.

Other:

Anesthesia/Pain Medication

I realize that many pain medications exist. I'll ask for them if I need them.  Please do not ask the pain scale.

Before considering an epidural, and if the situation warrants, I would like to try an injection of narcotic pain relief (Nubain, Demerol, Stadol or similar).

I would like to have an epidural.

Other:

Cesarean

Unless absolutely necessary, I would like to avoid a Cesarean.

If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making process.

I would like (coach) present at all times if the baby requires a Cesarean delivery.

So I can view the birth, I would like the screen lowered just before delivery of the baby.

If the baby is not in distress, the baby should be place skin-to-skin immediately after birth.

Other:

Episiotomy

I would prefer not to have an episiotomy unless absolutely required for the baby's safety. [Standard practice at OGN]

I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.

I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch.

If possible, I would like to use perineal massage to help avoid the need for an episiotomy.

Other:

Delivery

I would like to be allowed to choose the position in which I give birth, including squatting. [Standard practice at OGN]

I would like (partner) and/or nurses to support me and my legs as necessary during the pushing stage.

I would like to try to deliver in a hands-and-knees position.

I would like to try to deliver in a squatting position, using (coach) or a squatting bar for support.

I would like a mirror available so I can see the baby's head when it crowns.

I would like the chance to touch the baby's head when it crowns.

Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.

I would appreciate having the room lights turned low for the actual delivery.

I would appreciate having the room as quiet as possible when the baby is born.

I would like to have the baby placed on my stomach/chest immediately after delivery.

Other:

Immediately After Delivery

I would like to have (coach) cut the cord.

I would like (other) to cut the cord.

I would like to cut the cord myself.

(coach) does not wish to cut the cord.

I would prefer that the umbilical cord stop pulsating before it is cut. [Standard practice at OGN]

I would like to hold the baby while I deliver the placenta and any tissue repairs are made.

I would like to hold the baby for at least fifteen minutes before (he/she) is photographed, examined, etc.

I would like to have the baby evaluated and bathed in my presence.

I plan to keep the baby near me following birth and would appreciate if the evaluation of the baby can be done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation.

If the baby must be taken from me to receive medical treatment, (coach) or some other person I designate will accompany the baby at all times.

I would prefer to hold the baby rather than have (him/her) placed under heat lamps.

I would like to delay the eye medication / vitamin K / hepatitis B immunization for the baby until a 2 hours after birth.

I would like to donate the umbilical cord blood if possible.

I would like to bank the umbilical cord blood, and have made arrangements to do so.

I would like to see the placenta after it is delivered.

Other:

Postpartum

Unless required for health reasons, I do not wish to be separated from my baby.

I would like to have the baby "room in" and be with me at all times.

I would like to have the baby "room in" after I have had some time to recover.

I would like the baby with me during the day but in the nursery at night.

I would like the baby with me during the day but in the nursery at night, but brought to me for breastfeeding. (Note: be sure to check the breastfeeding preferences below.)

I would prefer the baby be kept in the nursery and brought to me upon request.

I would prefer the baby be kept in the nursery and brought to me upon request and for breastfeeding. (Note: be sure to check the breastfeeding preferences below.)

Other:

Breastfeeding

I plan to breastfeed the baby and would like to begin nursing very shortly after birth.

Unless medically necessary, I do not wish to have any bottles given to the baby (including glucose water or plain water).

I do not want the baby to be given a pacifier.

I do not plan to breastfeed the baby.

I would like more information about breastfeeding.

I would like to meet with a Lactation Consultant.

Other:

Circumcision

I do not want the baby circumcised

I do not wish to have the circumcision performed in the hospital.

I would like the baby to be circumcised before we check out of the hospital

Other:

Photo/Video

I would like to take still photographs during labor and the birth.  [Videograpy is prohibited at NAMC]

Other:

Other

My support people are (support people) and I would like them to be present during labor and/or delivery.

I would like my other child/ren to be able to visit me and the baby in the hospital.

I would prefer that no students, interns, residents or non-essential personnel be present during my labor or the birth.

Other:

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