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Printable Birth Plan Worksheet
When it comes to giving birth your way, putting it in writing can help. A Birth Plan is an optional wish list that lets you outline your hopes, indicate any concerns and tell us your preferences for when the time comes to labor and give birth. It’s a way to keep all your birth day care providers informed about what is most important to you.
A birth plan, or wish list, is a communication tool summarizing your “birth day” preferences. It is important to understand there is more than one way to do things, and every birth is unique and can be unpredictable. Try to remain flexible, positive, realistic, and limit it to what matters most to you.
WakeMed Health & Hospitals supports your wishes and desires when it comes to welcoming a new baby, and have created this wish list format to capture that information. It is our ultimate goal for both mom and baby to emerge happy and healthy after each and every birth. We are here to answer any questions you may have about the labor and birth process.
Things to Think About Before Going Into Labor
Pain Medication/Anesthesia Pain is an individual experience. The discomforts of labor and birth vary from woman to woman. We are here to help you effectively cope with these discomforts through the use of coping mechanisms such as movement, massage, position changes, breathing techniques and relaxation. When well supported and continuously encouraged, many women are able to give birth with few, if any, medications.
Should medications be requested, you and your health care provider can discuss available options to reduce your discomfort. Keep in mind, pain medications can ease discomfort, but they are not designed to eliminate all sensations.
You will be asked about your level of pain. We use a 0-10 scale with “0” being no pain and “10” being the absolute worst pain you can imagine. We encourage you to think about your pain tolerance level and use all available coping and comfort measures throughout labor and birth to help you to have a more satisfying birthing experience.
“P.A.I.N.” is… Purposeful – alerts and causes labor progress Anticipated – we expect some pain in labor Intermittent – it comes and goes, giving you a break Normal – nothing is more normal than labor pain
So that we may better serve you, please indicate your preference below. Remember you can change your mind at any point throughout labor.
I prefer to labor and give birth without pain medication. I am aware of pain medications available. I will ask if I would like something for pain. Please do not ask me.
I would like to have pain medications offered to me via IV before trying an epidural.
I would like an epidural as soon as possible. (Keep in mind, getting an epidural requires a team effort that takes 60-90 minutes to accomplish. We strongly encourage you to learn, practice and use all available coping and comfort measures while we work to place your epidural.)
Wish List for Labor (Check your wishes)
Labor Induction/Augmentation If I go past my estimated due date AND there are no health risks for me or my baby, I would prefer:
Not to be induced
To be induced
First Stage Labor (0-10 cm dilated)
I prefer… Lighting: Dim Bright Open curtains Television: On Off Quiet: During contractions All the time
Music (bring your own music & player)
Aromatherapy/essential oils (bring your own;
no lit candles in the hospital)
To wear a hospital provided gown
To wear my own clothes/sports bra
The following are my preferences (I understand these items are subject to approval by my health care provider according to the safety of me and my baby.)
I prefer no IV unless absolutely necessary.
If I need an IV, I would like to use a saline lock. A saline lock is a port that allows immediate access to the vein for IVIV fluids and/or medications if needed. The advantage is that you don’t have to be continuously connected to the tubing and IVIV bag with the pole.
Intermittent (off and on) fetal monitoring if the baby is not in distress.
Continuous fetal monitoring. I understand this may limit some mobility.
Second Stage Labor (Pushing) ~ I would like…
A mirror present (to help with pushing and to view birth)
To touch the baby’s head as it crowns
My coach or designated person to support my legs when I push
To use the squat bar during pushing
To try different positions during pushing
To delay pushing until I feel the urge even if I am fully dilated (Labor down).
Counting to help me push
No counting to help me push
To have my baby placed skin-to-skin immediately and to remain there long as baby is not having difficulty adjusting.
To have the baby dried and swaddled, by the nurse, before being brought to me.
To have _________________________ cut the cord.
To allow the cord to stop pulsating before clamping and/or cutting.
To bank the baby’s umbilical cord blood (bring your own collection kit from a cord blood banking company)
3000 New Bern Ave.
Raleigh, NC 27610