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Creating a Birth Plan Worksheet can empower expectant parents by clarifying their preferences for labor and delivery. The form includes essential details such as the due date, names of the parents, and individuals they wish to have present during the birth. It allows parents to express their educational background regarding childbirth, the methods they plan to use for pain relief, and their preferences for fetal monitoring. Important decisions regarding the delivery method—vaginal, C-section, or VBAC—are highlighted. The form also addresses the immediacy of post-delivery procedures, including skin-to-skin contact, delayed cord clamping, and the involvement of partners in cutting the cord. Additionally, it asks parents to comment on newborn care, such as the baby’s first bath and vaccinations. By reviewing this worksheet with healthcare providers and bringing it to the hospital, expectant parents can ensure that their wishes are acknowledged while still prioritizing safety for both mother and child.

Birth Plan Worksheet Example

My Birth Plan

Due Date:

Your Name:

Spouse/Partner's Name:

Others to be Present During Labor and Birth:

Childbirth Preparation/Education Method:

Doula/Birth Partner:

Pediatrician:

I understand that this document reflects my birth preferences, it is not a medical document, and that depending on the situation occurring, it may need to be altered for the safety of myself and my child. Ask your provider to review this with you and take it with you to the hospital when your labor begins.

My delivery is planned as:

Vaginal delivery

C-section

VBAC

During labor, I prefer:

Music played

Dimmed lights

Quiet room

As few interruptions

As few vaginal exams

Peanut ball

My partner to be present at all times Hydrate with clear liquids & ice chips

I am planning to collect Cord Blood

No Yes

Donation

Tissue

Blood

Company:

For pain relief, I prefer:

IV medications

Epidural

Only what I request at that time

Whatever is suggested

Nothing, please do not suggest epidural Comments:

During the 1st stage of labor, I prefer:

Standing

Laying down

Walking around

Comments:

For fetal monitoring, I prefer:

Continuous

Intermittent

I understand that if I am to be induced or need Pitocin started, continuous monitoring must be implemented.

If I need labor augmentation, I prefer:

Pitocin

Artificial rupture of membranes

Both

Comments:

For delivery position, I prefer:

Laying on back (regular position)

Laying on side

Hands and knees

Using birth bar

Squat

Comments:

I understand that an epidural or inability to monitor the baby appropriately may require a different position than I prefer.

As the baby delivers, I prefer to:

Be directed on pushing

Push spontaneously

Use a mirror to see the baby crown

Let the epidural wear off while pushing

Have a full dose of epidural

Touch the head as it crowns

Use mineral oil/lubricants

If I require assistance at delivery, I prefer:

Episiotomy

Operative delivery with forceps/vacuum Cesarean section

No preference

Immediately after delivery, I prefer:

Delayed cord clamping

Skin to skin

My partner to cut the cord

Baby to go to the warmer

Other:

Comments:

I understand that at Sibley, delayed cord clamping and skin to skin immediately after birth are standard. However, implementation is deemed by the pediatrician/doctors depending on the condition of the baby. Likewise, for cutting the cord, my partner may not be able to if the baby must be evaluated immediately.

I would like to hold baby:

Immediately after delivery

After suctioning

After weighing/measurements

After being wiped clean and swaddled

Comments:

I prefer baby's medical exams/procedures:

Given in my presence

Given in my partner's presence

Comments:

I prefer my baby's first bath be given:

In my presence

In my partner's presence

By me

By my partner

Comments:

For the placenta, I prefer:

To look at it before it is discarded

To take it home with me

To have it discarded

I understand that the placenta may need to be sent to the lab if the provider deems it necessary.

If a C-section is necessary, I prefer:

All other options have been exhausted

Explanation of risks/benefits and indication for the procedure

My partner to hold the baby ASAP

Breastfeed in the recovery room

I understand that my partner will be allowed in the operating room as long as there are no complications. I understand that delayed cord clamping is implemented standardly during C-section, unless the pediatrician needs to assess the baby immediately.

I would like to breastfeed:

As soon as possible after delivery

Later after resting

I prefer to bottle feed

Comments:

I would prefer the baby not to receive:

Vitamin K shot

Antibiotic eye ointment/drops

Formula

A pacifier

Comments:

I would like to feed baby:

Only with breastmilk

Only with formula

On demand

On schedule

With the help of a lactation consultant

Comments:

If we have a boy, circumcision should:

Be performed

Not be performed

Comments:

Signature:Date:

Form Characteristics

Fact Title Details
Purpose The Birth Plan Worksheet is designed to communicate a birthing person's preferences for labor and delivery to healthcare providers.
Due Date Section It includes a section for the due date, allowing providers to understand the timeline for the pregnancy.
Family Involvement Space is provided for including the names of partners and others who wish to be present during labor and birth.
Educational Preferences The worksheet asks about the childbirth education method that the birthing person has chosen, promoting informed decisions.
Pain Relief Options Individuals can specify their preferences for pain relief during labor, including options like IV medications or epidural anesthesia.
Delivery Preferences It allows individuals to express their preferred position for delivery, accommodating personal comfort during the process.
Immediate post-birth Wishes The form covers immediate post-delivery preferences, including skin-to-skin contact and delayed cord clamping.
Medical Procedures It provides options regarding the presence of the birthing person or partner during the baby's medical exams and procedures.
Rights and Understanding There is an acknowledgment section emphasizing the understanding that flexibility may be required based on medical circumstances.
State-Specific Forms The worksheet may vary by state according to local laws governing childbirth practices and parental rights.

Guidelines on Utilizing Birth Plan Worksheet

The Birth Plan Worksheet form serves as a way for expecting parents to communicate their preferences for labor and delivery. When filling it out, it’s essential to consider your individual desires and needs, ensuring that those involved in your care understand your wishes during this significant time. After completing the form, it is wise to discuss it with your healthcare provider and keep it handy for when labor begins.

  1. Begin by entering your Due Date at the top of the form.
  2. Next, fill in Your Name and your Spouse/Partner's Name.
  3. List any Others to be Present During Labor and Birth.
  4. Indicate the Childbirth Preparation/Education Method you have chosen.
  5. If applicable, write down the name of your Doula/Birth Partner.
  6. Provide the name of your Pediatrician.
  7. Acknowledge the statement about the form not being a medical document and the potential need for alterations.
  8. Select your planned delivery method: Vaginal delivery, C-section, or VBAC.
  9. Detail your preferences during labor by marking your choices, such as Music played, Dimmed lights, Quiet room, and others.
  10. Decide whether you plan to collect Cord Blood and specify if you want to donate it.
  11. For pain relief, mark your preferred options.
  12. During the first stage of labor, select your preferred position: Standing, Laying down, or Walking around.
  13. Choose your preferred method for Fetal monitoring.
  14. If labor augmentation is necessary, indicate your preferences.
  15. For the delivery position, select from the options provided.
  16. During delivery, specify your preferences regarding how you would like to push and any additional wishes.
  17. If assistance is needed, communicate your preference for delivery assistance.
  18. List your immediate post-delivery preferences such as Delayed cord clamping and Skin to skin.
  19. Indicate when you would like to hold your baby after delivery.
  20. State your preferences for your baby's medical exams/procedures and first bath.
  21. Address your preferences regarding the placenta after birth.
  22. In the case of a C-section, mark your preferences and considerations.
  23. Express your desires for breastfeeding, including when you would like to start.
  24. Specify any items you would prefer your baby not to receive.
  25. Choose how you would like to feed your baby.
  26. If applicable, indicate your choice about circumcision for a boy.
  27. Finally, sign and date the form to validate your preferences.

What You Should Know About This Form

What is the purpose of the Birth Plan Worksheet?

The Birth Plan Worksheet is designed to help expectant parents outline their preferences for childbirth. It serves as a personal guide to communicate desires regarding labor, delivery, and immediate postpartum care. This document may help healthcare providers understand and respect your choices while acknowledging that adjustments may be necessary based on medical circumstances.

What information do I need to fill out on the form?

Essential details to include in the Birth Plan Worksheet are your due date, your name, and your partner's name. Additionally, you should list individuals who will be present during labor and delivery and your chosen childbirth education method. Preferences related to pain relief, labor techniques, and post-delivery care will also need to be specified.

Can I change my preferences outlined in the worksheet during labor?

Yes, you may adjust your preferences during labor based on your circumstances. The document emphasizes that it is not a strict medical directive but rather a reflection of your initial preferences. It's important to remain open to changes for your safety and that of your baby, and you can consult your care provider for guidance at any time.

What happens if I need a C-section?

If a C-section becomes necessary, the worksheet includes preferences you can specify. For example, you can state your wishes regarding explanations of risks, your partner holding the baby afterward, and breastfeeding in the recovery room. It is essential to communicate these preferences to your provider prior to labor.

Is my partner allowed in the delivery room?

Your partner is typically allowed to be present in the delivery room throughout the labor and delivery process. The Birth Plan Worksheet confirms this, provided there are no medical complications that necessitate restrictions.

What are my options regarding pain relief?

You have several options for pain relief that you can indicate on the worksheet, including IV medications, epidural anesthesia, or choosing to only receive pain relief upon request. It is advisable to discuss these options with your provider to make informed decisions suited to your situation.

How should I prepare to take the Birth Plan Worksheet to the hospital?

Once you fill out the Birth Plan Worksheet, review it with your healthcare provider. It is crucial to ensure that it aligns with hospital policies and your medical care plan. Keep a printed copy readily available to bring with you as you start labor. This will ensure your preferences can be easily accessed by your care team.

What if I have concerns about newborn procedures?

The worksheet allows you to express your wishes regarding newborn procedures, such as vitamin K shots or antibiotic eye ointment. Clearly communicate your preferences and concerns with your healthcare provider to ensure they understand your choices regarding your baby’s immediate care.

Can I include special requests for the placenta after delivery?

Yes, there are options regarding the management of the placenta after delivery specified in the worksheet. You can express your wishes whether you want to look at it, take it home, or have it discarded. However, keep in mind that your provider may need to send it for lab analysis based on medical circumstances.

Common mistakes

Completing a Birth Plan Worksheet can be an important step in preparing for childbirth. However, many people make some common mistakes that can hinder the effectiveness of their birth plan. One of the most frequent mistakes is not discussing the birth plan with their healthcare provider beforehand. It's crucial to have a conversation about your preferences to ensure that they align with the medical team's capabilities and practices. Otherwise, what is on paper might not be feasible when the time comes.

Another common error is being too rigid in the preferences listed. While it's good to have a clear idea of what you want during labor and delivery, circumstances can change rapidly during childbirth. A mindset that allows for flexibility helps to accommodate any unexpected developments that could arise, like the need for a C-section or changes in pain management options. Being open to modifications can contribute to a more positive experience.

A third mistake people make is leaving out important details in the comments sections. This area is a valuable opportunity to express any specific desires or concerns regarding the birthing process. Failing to fill this part out can create confusion or misinterpretation about personal preferences. Providing clear information about your wants and needs can help the medical team support you effectively.

Finally, many individuals do not consider alternative plans for their baby's care after birth. While it's essential to state your preferences for immediate post-labor experiences, it’s also wise to think about what should happen if the baby requires additional medical attention. Planning for both scenarios ensures that your baby's health remains the top priority, while still honoring your desires when feasible. Taking the time to avoid these mistakes can make a significant difference in achieving a fulfilling birthing experience.

Documents used along the form

A Birth Plan Worksheet is a valuable tool for expecting parents to express their preferences regarding labor and delivery. Alongside this document, there are several other forms and records that can help ensure a comprehensive approach to the birthing experience. Each of these documents serves a distinct purpose in preparing for the arrival of a new baby.

  • Medical History Form: This document collects important information about the mother’s health and any previous pregnancies. It helps the healthcare provider understand any potential risks and tailor the care accordingly.
  • Consent for Treatment Form: This form is used to give permission for various medical treatments or procedures during labor and delivery. It is essential for protecting both the patient and the healthcare provider legally.
  • Hospital Registration Form: A registration form is typically completed before arriving at the hospital. It contains personal information and preferences and helps ensure a smooth admission process during labor.
  • Pediatrician Referral Form: This document allows parents to designate a pediatrician for their newborn. It's helpful for the hospital staff to understand who will provide postnatal care for the baby.
  • Delivery Preferences Form: Similar to the birth plan, this form outlines specific preferences for the delivery process itself. It may include desires for pain relief, support during labor, and the partner's involvement.
  • Pediatric Assessment Form: After delivery, this form ensures that the newborn receives necessary evaluations and screenings. It serves as a guide for the healthcare team regarding assessments the baby needs right after birth.
  • Postpartum Care Plan: This document addresses the mother’s care after delivery. It includes recommendations for recovery, breastfeeding support, and newborn care, helping ensure a healthy transition for both mother and baby.

The combination of the Birth Plan Worksheet and these additional documents supports clear communication between parents and healthcare providers. Together, they can help create a supportive environment for a positive birthing experience.

Similar forms

  • Birth Preferences List: Similar to the Birth Plan Worksheet, a Birth Preferences List outlines the specific choices and desires of expectant parents regarding labor and delivery. It can include preferences for pain management, birthing positions, and immediate postpartum care, much like the structured format of the worksheet.

  • Labor & Delivery Instructions: This document provides clear guidance on what the mother wants during labor and delivery. It often includes patient preferences regarding the presence of family, music, and comfort measures, aligning closely with the preferences detailed in the Birth Plan Worksheet.

  • Postpartum Care Plan: Similar to the Birth Plan Worksheet, this plan reflects the mother’s wishes for immediate postpartum care, such as bonding with the baby and breastfeeding preferences. It emphasizes personalized care following delivery.

  • Hospital Admission Form: An admission form typically requires basic personal details and medical history, ensuring that the hospital staff understands the patient’s background. Like the Birth Plan Worksheet, it captures essential information needed before and during the birthing process.

  • Patient Consent Forms: While primarily focused on legal consent for medical procedures, these forms also address patient preferences regarding medical interventions. This is similar to the Birth Plan Worksheet in that both documents highlight the importance of patient autonomy in determining care.

Dos and Don'ts

When filling out the Birth Plan Worksheet form, there are several important considerations to keep in mind. This list outlines actions to take and avoid for an effective completion.

  • Do provide clear information regarding your due date and names of those involved in the birthing process.
  • Don’t leave any sections blank; fill out all applicable fields to ensure comprehensive communication of your preferences.
  • Do discuss your birth plan preferences with your healthcare provider prior to labor.
  • Don’t ignore the possibility that your preferences may need to change during delivery for health and safety reasons.
  • Do bring the completed form with you to the hospital to inform the medical staff of your wishes.
  • Don’t forget to include pain relief methods and any specific newborn care preferences on the worksheet.

Misconceptions

  • Misconception 1: A birth plan is a legally binding document.
  • This is not true. The Birth Plan Worksheet is a reflection of preferences and does not have any legal standing in medical decision-making.

  • Misconception 2: All preferences in the birth plan must be followed exactly.
  • While the birth plan outlines preferences, medical professionals may alter plans based on safety and health considerations.

  • Misconception 3: A birth plan guarantees a certain type of delivery.
  • No delivery method is guaranteed. The Birth Plan is a guide to preferences but should remain flexible in case of unexpected situations.

  • Misconception 4: The birth plan is only relevant for vaginal deliveries.
  • The Birth Plan Worksheet is applicable for all types of deliveries, including Cesarean sections and VBACs, as it addresses preferences for various circumstances.

  • Misconception 5: A doula or birth partner is not important if you have healthcare providers present.
  • A doula or birth partner can provide emotional support and advocacy for the birthing person. Their presence can enhance the childbirth experience.

  • Misconception 6: Parents cannot change their birth plan once labor has begun.
  • Changes can and often do happen during labor. Open communication with healthcare providers is essential for adapting the plan as needed.

  • Misconception 7: The birth plan is only for first-time parents.
  • Any expecting parent, regardless of previous experience, can use this worksheet to express their preferences and make informed choices for their next delivery.

  • Misconception 8: Filling out the birth plan is enough preparation for labor and delivery.
  • While the birth plan is a helpful tool, it's essential to participate in childbirth education and discussions with healthcare providers for comprehensive preparation.

Key takeaways

Creating a Birth Plan Worksheet is a helpful way to communicate preferences for labor and delivery. Here are some key takeaways to consider when filling out and using the form:

  • Clarity of Preferences: This document allows you to clearly outline your wishes regarding labor and delivery. Be specific about choices for pain relief, monitoring techniques, and post-delivery care.
  • Flexibility is Important: While the Birth Plan reflects your wishes, childbirth can be unpredictable. Understand that adjustments may need to be made for the safety of both you and your baby.
  • Consultation with Healthcare Provider: Discuss your completed Birth Plan with your doctor or midwife. Their insights can help ensure your plan aligns with medical protocols and practices.
  • Communication with Support Team: Share your Birth Plan with everyone who will be present during labor. This includes your partner, doula, or any other support persons, so they understand your preferences.
  • Important Considerations: Be aware of essential aspects to include in your plan, such as delivery position, postpartum procedures, and newborn care, including preferences for screenings and baths.
  • Bring It to the Hospital: Remember to take your Birth Plan to the hospital when labor begins. This will help ensure that your preferences are communicated effectively to the medical team on duty.

By thoughtfully completing the Birth Plan Worksheet, you can feel more prepared and empowered as you approach your delivery experience.