Birth Plan

Out-Of-Hospital

Name ________________________________     Signature ______________________________________________

Care Provider__________________    Attending Birth: ______________________________________________

Most Important Issue:
Item                                                    Yes         No                            Comments


1. Labor to begin spontaneously, up to 42 weeks.

 

 

 

      I am bringing extra pillows or items to help with labor relaxation.

 

 

 

2.  Ability to move around during labor.

 

 

 

3..  Non-clinical pain relief during labor. Massage of hands, feet, back.  Optimal Fetal Positioning.

 

 

 

   Hydrotherapy- tub, shower, water birth,

 

 

 

     Medication for pain. 

 

 

 

4. Spontaneous rupture of membranes if warranted

 

 

 

5.  Minimum amount of fetal monitoring possible.

 

 

 

6.  Ability to eat and drink during labor.  Plans for nourishment.

 

 

 

7. Choose position for pushing:
 Semi-sitting, squatting, supported stand, birth stool, side-lying.

 

 

 

8.  Perineal hot compresses & olive oil for management of perineum during 2nd stage.

 

 

 

9.  Touch baby’s head when crowning.

 

 

 

10.  I would like to lift baby out after head and shoulders are born.

 

 

 

11.  Cord stopped pulsing before clamping.

 

 

 

12.  Natural descent of placenta, if possible.

 

 

 

13.  Baby stays with me at all times.  Any procedures done at my bedside, if possible.