Client Care PreferencesPlease fill out this form to create your birth plan. Birth Team Support & Environment Name of Mother * First Name Last Name Name of Father/Support Person First Name Last Name Birth Team Members * Please list any other birth team members and their roles (Midwife, OBGYN, Doula, Photographer, Other Family) Baby's Name * Name of Birthing Location Environment * Please check all that apply. Lights On Light Dimmed Music Playing Mood of Room * Please check all that apply Calm & Relaxed Upbeat & Happy Lighthearted & Joking Serious/No Side Chatter Labor Preferences Allergies Initial Check In * Please check all that apply No IV Saline Lock No Cervical Exams Cervical Exams by Provider Cervical Exams Permitted Fetal Monitoring Preference * Intermittent Continuous Internal Wireless GBS Care * If positive, I would like iv antibiotics. If positive, I do not want iv antibiotics. Currently undecided. GBS Negative Epidural * ASAP At 5cm Only When I Ask Do Not Offer Narcotic * Only When I Ask Do Not Offer Nitrous Oxide * Only When I Ask Do Not Offer Offer Please Labor Progression Methods * Check all that you are open to discussing with the medical team. Intimacy with Spouse Nipple Stimulation/Pumping Position Changes Breaking Amniotic Sack Pitocin Labor Comfort Measures * Check all that you are comfortable with. Changing Positions Shower/Tub Hot/Cold Packs Massage Acupressure Points Counter Pressure Birthing Preferences Preferred Pushing Method * Spontaneous/Follow Urges Directed/Coached Pushing with My Natural Breath Prolonged Pushing to the Count of 10 Perineal Care * Please check all that you are comfortable with. Massage Warm Compress Episiotomy Prefer to Tear Naturally Delivery Positions * Please check all positions that you are open to. Supported Squat/Squat Bar Semi-Sitting Side Pushing Hands & Knees On Back with Stirrups Birth Stool Water/Land Birth Preferences Catching Baby Please state your preference on who receives your baby upon birth. Cord Clamping Preferences * Clamp Immediately Delay Clamping for 60+ Seconds Delay Clamping Until Pulsing has Stopped Delay Clamping Until the Birth of the Placenta Cord Cutting * Partner Cuts Cord Mother Cuts Cord Provider Cuts Cord Placenta * Save for Encapsulation/Ingestion Save for Art Impression Save to Freeze Discard After Birth Newborn Care Preferences Blanket/Skin-to-Skin * Mark all that apply Wrap Baby in Blanket Immediate Skin-to-skin with Mother Skin-to-skin with Father if Mother is Occupied Exams/Measurements * Anytime after delivery Wait until after breastfeeding is established Delay for at least 1 hour Eye Ointment * Yes Please No Thank You Delay 1 Hour Vitamin K * Yes Please No Thank You Delay 1 Hour Oral Vitamin K Undecided Hep B Vaccine * Yes Please No Thank You What is your feeding preference for baby? * Foreskin Preference * Baby Girl: Does not apply Circumcision Leave Intact Undecided Additional Birth Preferences Thank you!
