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<div class="HwContainer HwElement" id="HwContainer"><a class="HwMainSkipNavigation" href="#HwContentTitle"><span class="HwAccessibilityText">Skip Navigation</span></a><div class="HwBlock" id="HwMain" role="main"><div class="HwRow"><div class="HwColumn" id="HwColumnSidebar1"><div class="HwCustom" id="HwCustomSidebar"> </div></div><div class="HwColumn" id="HwColumnContent"><div id="HwContentTop"> </div><div class="HwTypeFocus HwContentWrapper HwElement" role="article" id="HwContentWrapper"><div class="HwCustom" id="HwCustomContentTop"> </div><div class="HwContentHeader"><p><a name="top" id="Hwtop"><span class="HwAccessibilityText">Top of the page</span></a> </p></div><div class="HwContentTitle"><h1 id="HwContentTitle" tabindex="-1">My Birth Plan</h1></div><div class="HwContentTopNavigation"> </div><div class="HwContent"><div class="HwNavigationSection HwSectionSpecialSection" id="sec-abl1754"><h2 class="HwSectionTitle" fingerprint="b4cb0a40" fingerprint-exact="e7c3d1bb">Overview</h2> <p fingerprint="4e85f368" fingerprint-exact="8d48068d">Name: ___________________________________. Partner's name: _____________________________.</p> <p fingerprint="6dc4d475" fingerprint-exact="e6b6bea7">Doctor or midwife's name: __________________________. Today's date: _____________________.</p> <p fingerprint="7b07f5a0" fingerprint-exact="6ac353d6">This birth plan is a guide for my labor and delivery. Since childbirth does not always go as planned, some of this birth plan may change.</p> <h3 class="HwSubSectionTitle" fingerprint="73c6e9f4" fingerprint-exact="8ac63250">Place and people</h3> <p fingerprint="4db6df65" fingerprint-exact="246a66a6">I would like to deliver my baby:</p> <p fingerprint="569ad6b3" fingerprint-exact="0343aa85">__ In a hospital: _______________________________________(name, phone number).</p> <p fingerprint="235f3fd2" fingerprint-exact="e87198a5">__ In a birthing center: _______________________________________(name, phone number).</p> <p fingerprint="963813c7" fingerprint-exact="34c26262">__ At home.</p> <p fingerprint="fbda3cbc" fingerprint-exact="1602cc14">I would like my baby to be delivered by:</p> <p fingerprint="26abe809" fingerprint-exact="eadd4bae">__ My family doctor: _________________________________________(name).</p> <p fingerprint="ac1fc247" fingerprint-exact="02fe46d0">__ My obstetrician: ________________________________________________.</p> <p fingerprint="454a7ea5" fingerprint-exact="7e2f1f3f">__ My midwife: ____________________________________________________.</p> <p fingerprint="bc136400" fingerprint-exact="4eac78a3">__ My perinatologist: _______________________________________________.</p> <p fingerprint="77b6ed7b" fingerprint-exact="0f194890">I'd like these people to be with me during labor and birth:</p> <p fingerprint="2f0e9a39" fingerprint-exact="a1890f03">__ Partner: ________________________________________________(name).</p> <p fingerprint="c295a686" fingerprint-exact="7cb69d7f">__ Friend(s): _____________________________________________________.</p> <p fingerprint="3fd66351" fingerprint-exact="dfd148d4">__ Family: _______________________________________________________.</p> <p fingerprint="f9171562" fingerprint-exact="053619d7">__ Doula: ________________________________________________________.</p> <h3 class="HwSubSectionTitle" fingerprint="7302960e" fingerprint-exact="8c06300f">During labor</h3> <p fingerprint="6acc2a52" fingerprint-exact="c6d6e61b">__ I'd like to be able to go back home if I'm not in active labor.</p> <p fingerprint="2efcf780" fingerprint-exact="019c1d21">After I've been admitted, I'd prefer:</p> <p fingerprint="d7899721" fingerprint-exact="5dc05e1f">__ To eat if I wish to.</p> <p fingerprint="62165e51" fingerprint-exact="8cdc176e">__ To drink clear fluids instead of having an IV.</p> <p fingerprint="ed361dd2" fingerprint-exact="193ab169">__ To walk and move around if I can.</p> <p fingerprint="4033e013" fingerprint-exact="65aa72e4">I'd like to try:</p> <p fingerprint="891dcab6" fingerprint-exact="01b22e0f">__ A birthing chair.</p> <p fingerprint="250b1b66" fingerprint-exact="97676249">__ A birthing stool.</p> <p fingerprint="faa3e15a" fingerprint-exact="f338a803">__ A squatting bar.</p> <p fingerprint="433801f0" fingerprint-exact="2dd166e4">__ A birthing tub or pool.</p> <p fingerprint="bbe5bce0" fingerprint-exact="fddc4b8b">When the time comes to push, I'd like to:</p> <p fingerprint="18f85b86" fingerprint-exact="75ded8b8">__ Be coached on when to push and for how long.</p> <p fingerprint="e133401e" fingerprint-exact="d9c192b6">__ Push when I feel I need to (instinctively).</p> <p fingerprint="85ea54ed" fingerprint-exact="c9dac659">I'd prefer to use the following position(s):</p> <p fingerprint="25d38953" fingerprint-exact="9c946e65">__ Half lying down (semi-reclining).</p> <p fingerprint="2f89a5b8" fingerprint-exact="8347bc8c">__ Squatting.</p> <p fingerprint="b5536a74" fingerprint-exact="9c1b01f5">__ Lying on my side.</p> <p fingerprint="8d2661ba" fingerprint-exact="d7f5b7e4">__ Whatever feels best at the time.</p> <p fingerprint="b2a1856e" fingerprint-exact="5fb36329">I'd like to use the following for pain management:</p> <p fingerprint="a2fab9c1" fingerprint-exact="44526ea4">__ Acupressure</p> <p fingerprint="b9fdd566" fingerprint-exact="23958510">__ Breathing techniques</p> <p fingerprint="c48f0faa" fingerprint-exact="21046e62">__ Self-hypnosis</p> <p fingerprint="565e038e" fingerprint-exact="77a4d674">__ Massage</p> <p fingerprint="c5e8f213" fingerprint-exact="3b6acef0">__ Medicine</p> <p fingerprint="89957828" fingerprint-exact="100a94ee">__ Other: _______________________________________________________________.</p> <p fingerprint="cc586240" fingerprint-exact="9ce8d405">__ Please do not offer me pain medicine. I'll ask for it if I need it.</p> <p fingerprint="6209743e" fingerprint-exact="fbcc21a9">If I decide to use medicine for pain, I prefer:</p> <p fingerprint="541d1ec4" fingerprint-exact="e1aec84f">__ Epidural anesthesia.</p> <p fingerprint="4581fda3" fingerprint-exact="563adef5">__ Local anesthesia.</p> <p fingerprint="55fb87b4" fingerprint-exact="401f6164">__ Pudendal or paracervical block.</p> <p fingerprint="fe274d40" fingerprint-exact="5d5df2c2">__ An opioid.</p> <h3 class="HwSubSectionTitle" fingerprint="14149afa" fingerprint-exact="3cb1821f">Birth</h3> <p fingerprint="f0391532" fingerprint-exact="1d1c59a4">I would like to:</p> <p fingerprint="626ee4ad" fingerprint-exact="3c2a7cdd">__ Take all possible steps to avoid an episiotomy.</p> <p fingerprint="d7424515" fingerprint-exact="c358099e">__ View the birth using a mirror.</p> <p fingerprint="0186e23f" fingerprint-exact="9a61b230">After the birth, I'd like to:</p> <p fingerprint="97627042" fingerprint-exact="fadddd1a">__ Hold my baby right away, before any procedures that are not urgent.</p> <p fingerprint="e02329f5" fingerprint-exact="8e0d4b95">__ Breastfeed as soon as possible.</p> <p fingerprint="5423f3dc" fingerprint-exact="1f30c1e3">__ Have my partner cut the umbilical cord.</p> <h3 class="HwSubSectionTitle" fingerprint="4c967505" fingerprint-exact="518b7bd9">C-section</h3> <p fingerprint="68a964c5" fingerprint-exact="3f9d726f">If I have a C-section, I:</p> <p fingerprint="b1c1ec0a" fingerprint-exact="3a521420">__ Would like to see my baby coming out.</p> <p fingerprint="8b3fd77c" fingerprint-exact="6b045271">__ Would like my partner present during the operation.</p> <h3 class="HwSubSectionTitle" fingerprint="462cfc14" fingerprint-exact="8ef7ffa4">After the birth</h3> <p fingerprint="f985862c" fingerprint-exact="5dca65b7">After delivering the baby, I'd like to:</p> <p fingerprint="a5a2c5d5" fingerprint-exact="55939ba6">__ Have my partner be with the baby whenever I can't be.</p> <p fingerprint="43a25577" fingerprint-exact="8b95551a">__ Stay in a private room.</p> <p fingerprint="e83ce513" fingerprint-exact="34deb70c">__ Have my partner stay with me in my room.</p> <p fingerprint="970750d3" fingerprint-exact="84ddaf78">__ Breastfeed only.</p> <p fingerprint="67699289" fingerprint-exact="555ed54d">__ Bottle-feed with formula only.</p> <p fingerprint="82944c19" fingerprint-exact="66d81d04">Please offer my baby:</p> <p fingerprint="acff26c4" fingerprint-exact="f75084d1">__ Formula.</p> <p fingerprint="9c279cbe" fingerprint-exact="6e060bc5">__ Pacifier.</p> <p fingerprint="359766d5" fingerprint-exact="ddc09d8b">__ Nothing without my permission.</p> <p fingerprint="da9db6cb" fingerprint-exact="d217f721">I'd like my baby to be:</p> <p fingerprint="acc623f4" fingerprint-exact="4845b61b">__ In my room 24 hours a day.</p> <p fingerprint="3e49d3b1" fingerprint-exact="dd1a265b">__ In my room only when I'm awake.</p> <p fingerprint="b725454a" fingerprint-exact="59d8d9d3">__ With me only for feeding.</p> <p fingerprint="75e46d46" fingerprint-exact="ac05e6b8">__ With me based on how well I feel at the time.</p> <p fingerprint="21df1617" fingerprint-exact="232ca6a3">If I have a baby boy:</p> <p fingerprint="9fd78b48" fingerprint-exact="d6d0d581">__ I'd like him circumcised at the hospital.</p> <p fingerprint="12e0af25" fingerprint-exact="9b4ea12b">__ I'll have him circumcised later.</p> <p fingerprint="a3858784" fingerprint-exact="8379ffb7">__ I will not have him circumcised.</p> <p fingerprint="aee2bcf1" fingerprint-exact="90eeb276">__ I'll decide about circumcision later.</p> </div><div class="HwNavigationSection HwSectionRelatedInformation" id="sec-abl1753-RelInfo"><h2 class="HwSectionTitle" fingerprint="d5f858e0" fingerprint-exact="c0ffe04b">Related Information</h2><ul fingerprint="8e60eb0a" fingerprint-exact="9f47df58"><li class="HwOptionalAny"><a data-hw-type="Focus" data-hw-document-href="abp9162" data-hw-section="abp9163" hw:document-type="Focus" 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