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My Birth Plan and Labor Preferences

My Birth Preferences Form (Header)

You can't control every aspect of the labor and delivery process, particularly in the case of a high-risk pregnancy, but having a plan will allow you the opportunity to discuss with your obstetrician your preferences of how you'd like your baby's birth to be handled. It will not only assist before you go into labor, it will also communicate your wishes to other members of the team such as your labor-and-delivery nurse and your midwife, while you're in active labor.

Take some time and write your responses to the questions in the following form. Then print out a copy to use as discussion with your healthcare provider at your pre-natal appointment.

Please understand that this form reflects your ideas/suggestions only, and that medical necessity may override your preferences in order to best care for you and your baby.

I'd like the following individual to be present before AND/OR during labor:

Please check our website for the latest visitation guidelines. May be asked to leave the room for privacy questions during admission, epidural placement or during an emergency, if necessary.

During labor, I'd like:

I'd like to spend the first stage of labor:

For pain relief, my top 3 choices are:

During delivery, my top 3 choices are:

Immediately after birth, I would like:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

If a cesarean is necessary, I would like:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I would like to breastfeed:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I would like baby's medical exam and procedures:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I'd like baby's first bath given:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I would like to feed baby:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I'd like my spouse/partner to:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

If we have a boy, a circumcision should:

If baby is not well, I'd like:

Indicates standard of care if mother and baby are both stable, unless mother wishes otherwise.

I would like visitors on the mother-baby unit limited to:

Please check our website for the latest visitation guidelines.

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If your situation is an emergency, call 911.

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