Interactive Birth Plan

Nine months seems a long time. For some the period feels like it goes on forever. Plenty of time to arrange everything. Some things you plan to do simply slip by. A birth plan is one of the most important steps you can take to maintain control of your birth experience. Probably you have already decided on how you want it to be. Now is your opportunity to write it down, print it out and discuss it with your medical practitioners, hubby, hospital etc.

By using the 'Interactive Birth Plan' you will acquaint yourself with the various methods of pain management and childbirth choices which will help you realise your childbirth preferences. There are more options available than the traditional hospital labour and delivery and you will want to strive towards the ideal birth experience for you and your family.

The form below will ask several question regarding your personal preferences. If you're unsure, use the corresponding links to the right to research that particular topic. Once you've completed the form, print a copy and take it to your doctor or midwife. If you decide to make changes based on that conversation, return and create your final version. Print several copies, one for you, your partner, nurse and doctor but keep in mind that childbirth can't always be a planned event. Aim for your plan but keep an open mind without unreasonable expectations. What matters most is you and your baby's health and well-being.

Please fill in all required fields. Optional questions must have a check to the left of the question.

Personal Details
	Your first name? (required)
	Your last name? (optional)
	What is your husband, coach or partner's name? (optional)
	Title of Birth Plan: (your birth plan will be titled "My Birth Plan" unless you erase the contents or edit it with your own title)
	When is your Due Date? (Optional) Date/Month/Year
	Name of your doctor or midwife? (Optional)
	Birth assistant name? (Optional, if you have one and want her/him included)
	Place of Birth (Optional)
	This Birth Plan is Prepared for:
		Normal Delivery (vaginal)
		Caesarean
		Induction
		Twin or multiple birth
		VBAC (vaginal birth after caesarean)
		other (please type)

The following statement will appear on your birth plan unless you erase the contents or edit it with your own words. This is a statement of our birth plan and childbirth choices. We have been well informed prior to making these decisions. We realise that complications can arise and in such instances trust our caregivers to make necessary decisions on our behalf.

	My Personal Preferences Check as many as you would prefer.				Suggested reading for choosing your environment
	Private Birthing Room				> >	Choosing a Hospital How do hospitals differ?
	Dim Lights
	Peace and Quiet				Glossary For Labour and Delivery Terms you should know after-birth amniotic fluid amniotomy analgesic anterior Apgar score asymptomatic back labour bilirubin biophysical profile birth canal bloody show bradycardia Braxton-Hicks contractions breech presentation caput succedaneum (caput) cephalopelvic disproportion cervical gel cervical incompetence cervicitis caesarean section chorioamnionitis circumcision contraction contraction stress test cord blood banking cord compression crowning delivery room dilation Doppler ultrasound dystocia effacement electronic foetal monitor engagement epidural epidural block episiotomy external cephalic version foetal distress foetal monitoring foetal presentation Fetoscopy fontanelle footling presentation forceps delivery induction isolette IUPC (intrauterine pressure catheter) Lamaze molding mucus plug natural childbirth neonate neonatologist paediatrician perinatal perinatologist persistent foetal circulation Pitocin® placenta placenta accreta post partum postnatal care premature Infant prolapsed cord prolonged labour Rh incompatibility rooming-in small for gestational age umbilical cord umbilical hernia ultrasound uterus vacuum extraction vaginal birth vaginal birth after caesarean (VBAC) ventilator vernix vertex very low birth weight (VLBW) viable
	Bring our own Music
	Wear my own clothes
	Private Phone
	We would like to video labour and birth.
	We would like to take pictures during labour and birth
	No unnecessary exams or visits by students, residents, etc
	Minimal vaginal exams (Vaginal exams can actually cause problems such as infection and premature rupture of membranes.)
	Other (Please specify):

	Procedures and Labour: Check as many as you would prefer.
	Free to walk around, go to the bathroom throughout labour.
	Freedom to move in bed only (up to the bathroom)
	Mobility not important (catheter, used with regular epidural)
	I would prefer to avoid an enema and/or shaving of pubic hair.
	I would like to be able to eat & drink whatever I want.
	I would like to be free to drink clear fluids.
	I would like Ice Chips available to me at all times.
	Heparin/Saline Lock (Most hospitals require this as access to a vein should an emergency occur, it can also be used in place of an IV for administration of antibiotics for complications such as MVP or Beta Strep).
	I do not want an IV unless I become dehydrated.
	I would like to choose my positions for pushing and giving birth.

	Monitoring: You may choose intermittent or continuous monitoring.
	I do not wish to have continuous foetal 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.
	I prefer foetal monitoring.

	In the event that I require or have chosen foetal monitoring, my preference is:
	Fetoscope
	Doppler ultrasound
	External Foetal Monitor
	Internal Electronic Monitor

	Pain Relief Options: Select One of the following
	Option 1 I plan to give birth naturally without medication and will be coping with pain using the following techniques. Check this option then to continue ... >click here
	Option 2 I am attempting a natural childbirth but if I ask for pain medication I'd like to use: Check this option then to continue ... >click here
	Option 3 Please administer pain medication as soon as possible. Check this option then, to continue ... >click here

	Select options here if you chose 'Option 1' Choose as many as you wish:
	Bradley Method
	Lamaze
	Water (Shower or tub)
	The Alexander Technique
	Massage
	Acupressure
	Other (Please specify):

	Select one or more of the following if you've chosen option 2 or 3.
	Stadol		Nubain	Demerol
	Walking Epidural (low dose)			Epidural block
	Other (Please specify):

	Induction/Augmentation Check here if you want induction/augmentation preferences included in your birth plan
	Upon agreeing to an induced labour you will forfeit many options for your safety and health but preparing a birth plan and discussing your expectations and preferences with your primary care giver is recommended. Please note, there are natural methods for inducing labour we are not listing here. You may wish to try these before consenting to a hospital induction.

	Induction:
	I do not wish to have the amniotic membrane ruptured artificially unless their are signs of foetal distress.
	If labour is not progressing, I would like to have the amniotic membrane ruptured before other methods are used to augment labour.
	I would prefer to be allowed to try changing position and other natural methods before medical methods or medications are used.

	If you choose to be induced or it becomes medically necessary please state your preferences: Choose as many as you wish:
	Pitocin
	Prostaglandin gel
	Amniotomy

	Complications & Caesareans Check here if you want complications & caesareans preferences included in your birth plan
	Unless absolutely necessary, I would like to avoid a Caesarean
	If my primary caregiver recommends a caesarean birth I would like a second opinion if time warrants.
	If my primary physician recommends a Caesarean. I accept and will cooperate with the procedure at any time.

	Normal Childbirth (vaginal delivery) Check here if you want Normal Childbirth (vaginal delivery) preferences included in your birth plan
	I would like a mirror available so I can see the baby's head when it crowns.
	I would like to have the baby placed on my stomach/chest immediately after delivery.
	I would like to try to deliver in a hands-and-knees position.
	Please dim the lights for the birth
	I would appreciate having the room as quiet as possible when the baby is born.

	Placenta
	I want an injection of Pitocin after the delivery to aid in expelling the placenta.
	I do not want a injection of Pitocin after the delivery to aid in expelling the placenta.
	I would like to see the placenta after it is delivered.

	Episiotomy
	Prefer No Episiotomy (Massage, compresses, positioning, etc). (Select this one if you would prefer no episiotomy but not to the point of tearing).
	Prefer to Tear (Massage, compresses, positioning, etc). (Select this option if you would prefer to tear than have an episiotomy).
	Episiotomy
	Pressure Episiotomy (Done without anaesthesia, although you cannot feel it due to the pressure from the baby's head).
	Local Anaesthesia (for repair)

	Caesarean Delivery Check here if you want caesarean preferences included in your birth plan
	If you're scheduled for a Caesarean birth or if it becomes medically necessary for the health of you or your baby please state your preferences.
	Spinal/epidural anaesthesia
	General anaesthesia
	I would like my partner or coach present
	I would like my partner to be able to take Video/Pictures
	Screen lowered to view birth
	Touch the baby as soon as possible
	Partner to cut cord
	Other (Please specify):

	Baby Care Check here if you want Baby Care preferences included in your birth plan
	Umbilical Cord:
	Partner would like to cut cord
	I would like to cut the cord
	Neither of us wishes to cut the cord

	Eye Care: Choose only one
	None
	Delayed for bonding time
	Immediate

	Feeding Baby: Choose one feeding method, and you have an additional option for pacifiers.
	Breast feeding only
	Bottle feeding only
	Combination
	No pacifiers or glucose water (This would be to avoid nipple confusion).

	Separation Choose only one, although you can change your mind after the birth.
	No separation. Baby/ Mother rooming in.
	Delayed (after recovery period).
	Partial Rooming-In (Baby with mother during day, but not night).
	Nursery (baby brought to you on your schedule).

	Circumcision
	In the Hospital
	Parents Present
	Use anaesthesia (Depends on the practitioner)
	None (Check here if you do not intend to have the baby circumcised, or if you do not intend to have him circumcised at the birth place).
	Do not retract the foreskin

	Sick Infant: Choose as many as you would like.
	Breast feeding as possible
	Unlimited visitation for parents
	Handling the baby (holding, care of, etc).
	If baby is transported to another facility, move us as soon as possible
	Other (Please specify):

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