Thursday, September 11, 2014

Birth Plan Check Sheet

Prenatal Care

Routine blood tests only
Alpha-Fetoprotein test only between 16 & 18 weeks
No Alpha-Fetoprotein Test
Ultrasound between 14 & 20 weeks only
Ultrasound testing only if a serious problem is suspected
No ultrasound testing
Routine amniocentesis if over 35 years of age
Amniocentesis only if serious problem suspected
No amnocentesis
Routine Glucose Tolerance Test
Glucose Tolerance Test if urine contains sugar
Glucose Tolerance Test only if pre-existing diabetes suspected
No Glucose Tolerance Test
Routine Prenatal Rhogam injection
Rhogam injection within 72 hours after birth
Rhogam injection only if baby's blood is positive

Premature Labor

Use of drugs to prevent contractions
Cortisone shots to help baby's lungs mature
A glass of wine to relax the uterus and absolute bedrest
Baby born when it is ready


No enema routinely administered when entering hospital
Self-administered at home
Can be requested at the hospital
Can by suggested by doctor or midwife late in labor to help baby progress

Shave Pubic Hair

No routine shave
Clip hair around vaginal opening

Presence of Others

Father of baby only
Doula only
Father and Doula both present
Mother, sister, or other family member
Older siblings
Close friends and acquaintances
No one else present

Labor Positions

Laboring out of bed/walking
Any position comfortable to the mother which helps progress of labor such as but not limited to:
Supported Squat
Chair straddle
Rocking chair
Laboring in water
Under no circumstances should mother lie on her back to labor, be monitored, or examined


Water, fruit juice, herbal tea, broth, crackers, toast, light high-carb foods
Ice chips only
IV fluids only when medically indicated

Vaginal Exams

Only at mother's request
Only when labor changes

Fetal Heart Monitor

As little as necessary, and only with mother not on back
Doptone only
Fetoscope rather than doppler
Intermittent external monitor
Continuous external monitor only when medically indicated
Continuous internal monitor only when medically indicated
No monitoring

Pain Relief

Non-medical coping techniques:  relaxation, breathing, positioning, comfort measures, Doula
Medications or anesthesia only when mother requests them; medical staff will make no offers
Routine medication, narcotics or regional (epidural, spinal, etc.)

Augmentation of Labor

Changing position
Nipple stimulation
Intimacy with partner
Enema during active labor
Surgical rupture of membranes
IV Pitocin


Walk to toilet as often as possible
Bed Pan

Birthing Positons

Mother's Choice
Labor/birthing bed
Squatting with squat bar
Squatting with partner assistance
Birthing chair/stool


Spontaneous with exhale pushing
Directed with sustained pushing
Spontaneous with no pushing of any kind

Accelerate Delivery

Gravity-enhancing positions
Position change every 20 minutes
Prolonged pushing on command
Episiotomy if necessary
Vacuum extractor/forceps only if medically indicated

Perineal Care

Support, hot compresses, massage to avoid episiotomy
Anesthesia, episiotomy, stitches
Ice packs and sitz baths after birth


Dim lights, soft music, quiet voices, gentle, respectful attitude
Standard lighting and noise level
Delivery/operating room

Delivery of Placenta

Encouraged by baby nuzzling, sucking, or manual nipple stimulation
Massage of fundus by caregiver

Cord Cutting

Clamp and cut only after pulsating has stopped
Partner cuts cord
clamp and cut immediately if medically indicated
Lotus birth - cord stays attached for 2-7 days


No suctioning unless necessary
Suction with bulb syringe
Suction with DeLee mucus trap
Meconium - respiratory therapy evaluation


Baby skin-to-skin with mother, warm blanket over both, hat for baby
Placed in warmer
Placed in thermostatically-controlled isolette

Immediate Care

Baby handed to mother immediately, nursed as desired, observed in mother's arms
No routine care for at least one hour after birth
Newborn procedures done in mother's room
Taken to nursery for observation, weighing, feeding, routine care

Eye Care

None, waiver required
Non-irritating ointment at least one hour after birth

First Feedings

Breastfeeding on demand, no sugar water, sterile water, pacifiers
Breast milk expressed and given by dropper or bottle in nursery
Water(glucose or sterile) given by dropper by parents
Water (glucose or sterile) give by dropper or bottle in nursery
Formula feeding on demand


With parent(s) present to comfort baby
With no anesthesia
With anesthesia
Out-of-hospital circumcision on 8th day

Discharge of Mother and Baby

When desired
Early release; within 6 to 12 hours after birth (arrange in advance)
One or more days after birth (check insurance coverage)
Write down discharge weight of baby

Cesarean Birth

Only after labor begins, only when situation is life-threatening in mother's opinion
Scheduled before labor begins with adequate fetal maturity studies

Partner's Presence

Partner present during Cesarean
Partner obtains Cesarean preparation
Partner not present


Regional with little or no pre-medication
General anesthesia for emergencies only


Mother wears glasses or contacts
Screen lowered at time of delivery
Anesthesiologist or obstetrician explain events as they occur
Mother has contact with baby ASAP

Contact with Baby

Partner holds baby near mother; unlimited access
Breastfeeding ASAP
Sent immediately to nursery or NICU
Partner accompanies baby to nursery

Hospital Stay

Mother has cesarean roommate, if any
Mother on OB floor, not surgical floor


Minimum two day stay
3-4 days average
After you have made decisions about the care you will receive while giving birth, you will need to write these in the form of a birth plan.  This plan should be written in such a way that anyone who reads it will feel you have thoroughly researched the options, given a great deal of thought to your situation, and arrived at the best possible choices for you and your family.

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