BIRTH PLAN WORKSHEET

fill out the WORKSHEET below

(Psst.. This form is for established clients. If you’re looking to contact me, click below:)

The following worksheet is designed to help you create your birth plan. We can do this together at a prenatal visit, or you can fill it out on your own. If you wish, I can plug your responses into a document to share with your care team. Some questions are for my own knowledge prior to arriving to your birthing destination. It is your right to omit any and all information you do not wish to share.

Please reach out with any questions!

Pregnant Person's Name

First Name

Last Name

Pregnant Person's desired pronouns

Doula Name(s)

(###)

###

####

Partner/Support Person's Name

First Name

Last Name

Additional Support Person's Name

(If Applicable)

First Name

Last Name

Estimated Due Date

YYYY

Care Provider

Name of hospital/birth center:

EARLY LABOR

I plan to spend early labor at: (location)

Names of support person(s) and/or family who will be with me:

I would like my doula to communicate with me via/during:

(I.e. text/call during early labor)

I would like for my doula to come to me when:

(Please note if you call me to you and labor is still extremely early, I may leave again until things progress further)

My plan for transportation to my birthing location is:

(Doula will drive herself separately)

I plan to head to my birthing location when:

ACTIVE LABOR AT BIRTHING LOCATION

Support person(s) who will be with me at birthing location:

(Include name and relation)

My wishes for movement (walking around):

My wishes for fetal heart monitoring:

My wishes for internal/cervical exams:

My wishes for the room atmosphere:

(music, aromatherapy, quiet, etc.):

Is it important to you that non-emergency treatment plans be explained to you in advance? Would you like time to discuss and decide with your support person(s) before treatments continue?

If an IV is administered, would you like to ensure mobility? (That you can still move/walk around)

Please indicate any preferences regarding other medicinal interventions.

This can include the usage of AROM (artificial rupture of membranes), Pitocin, Forceps, Oxygen, Cytotec, Cervidil, etc.:

Do you wish to plan for a non-medicated (aka "natural") birth?

What are your preferences on an epidural?

Other labor preferences:

PUSHING + DELIVERY

Pushing positions I would like to try are:

My pushing preferences are: (Directed, with urge)

Do you want to be given a mirror to see the baby’s head? Do you want to reach down and touch baby’s head?:

Where would you like support person(s?) Do you want partner to look at/touch baby crowning?

Perinium care preferences:

Would you like to avoid an episiotomy, if possible?

(Many clinicians will allow a natural tear if one is necessary)

IF A C-SECTION BECOMES NECESSARY, THESE ARE MY WISHES:

Anesthesia:

Who will accompany me to the O.R

I would like my support person(s) to be

(i.e., at my side, holding my hand, etc):

Environmental or Other requests:

(i.e. unless it is an emergency, please try to keep a calm environment, refrain from private conversations between medical staff, please keep me updated with all steps)

IMMEDIATE POSTPARTUM

Who will cut the cord?

Plans for cord blood:

(keep, donate)

Do you want to see and/or keep the placenta?

Would you like to initiate breastfeeding? Would you like to allow baby to crawl to breast and initiate instinctually, or begin initiation with help of doula/staff?

PREFERENCES FOR BABY

For hospital births, please check your preferences for baby's treatment:

Give all standard treaments/immunizations

Waive Erythromycin Eye Ointment

Waive Vitamin K shot

Waive PKU test

Waive Glucose test

Waive Hepatitis B vaccine

Circumcision preferences:

Do you plan to bottle feed and/or give a pacifier?

If your baby needs treatment in the NICU, would you like your partner to stay with you or accompany the baby?

OTHER

The most important thing to me about my birth is:

Prior to birth, I would like to discuss/learn more about:

Any other notes/preferences: