Your Birth Plan

THERE'S A LOT TO CONSIDER WHEN WRITING A BIRTH PLAN.

THE BUMP BIRTH PLAN TOOL BREAKS DOWN ALL THE

KEY QUESTIONS TO HELP GET YOU STARTED.

While much of what happens during delivery is way beyond your (or anyone’s!) control, creating a birth plan will at least make your wishes clear. Definitely talk the plan over with your doctor—it’s important to make sure you’re both on the same page.

Read on for a checklist of things to consider when creating a birth Plan, and download The Bump Birth Plan form below. Remember that the options included on The Bump plan may not be available with every doctor or birthing center. 

Birth Plan:

[ ] Full name: [ ] Partner’s name: [ ] Today’s date: [ ] Due date: OR Induction date: [ ] Doctor’s name: [ ] Hospital name:

Please note that I:
[ ] Have group B strep
[ ] Am Rh incompatibility with baby
[ ] Have gestational diabetes

My delivery is planned as:
[ ] Vaginal
[ ] C-section
[ ] Water birth
[ ] VBAC

I’d like…:
[ ] Partner:
[ ] Parents:
[ ] Other children:
[ ] Doula:
[ ] Other:
…present before AND/OR during labor

During labor, I’d like:
[ ] Music played (I will provide)
[ ] The lights dimmed
[ ] The room as quiet as possible
[ ] As few interruptions as possible
[ ] As few vaginal exams as possible
[ ] Hospital staff limited to my own doctor and nurses (no students, residents or interns present)
[ ] To wear my own clothes
[ ] To wear my contact lens the entire time
[ ] My partner to film AND/OR take pictures
[ ] My partner to be present the entire time
[ ] To stay hydrated with clear liquids and ice chips
[ ] To eat and drink as approved by my doctor

I’d like to spend the first stage of labor:
[ ] Standing up
[ ] Lying down
[ ] Walking around
[ ] In the shower
[ ] In the bathtub

I’m not interested in:
[ ] An enema
[ ] Shaving of my pubic area
[ ] A urinary catheter
[ ] An IV, unless I’m dehydrated (and a heparin or saline lock IS/IS NOT ok)

Immediately after delivery, I would like:
[ ] My partner to cut the umbilical cord
[ ] The umbilical cord to be cut only after it stops pulsating
[ ] To bank the cord blood
[ ] To donate the cord blood
[ ] To deliver the placenta spontaneously and without assistance
[ ] To see the placenta before it is discarded
[ ] Not to be given Pitocin/oxytocin

If a C-section is necessary, I would like:
[ ] A second opinion
[ ] To make sure all other options have been exhausted
[ ]To stay conscious
[ ] My partner to remain with my the entire time
[ ] The screen lowered so I can watch baby come out
[ ] My hands left free so I can touch the baby
[ ] The surgery explained as it happens
[ ] An epidural for anesthesia
[ ] My partner to hold the baby as soon as possible
[ ] To breastfeed in the recovery room

I would like to hold baby:
[ ] Immediately after delivery
[ ] After suctioning
[ ] After weighing
[ ] After being wiped clean and swaddled
[ ] Before eye drops/ointment are given

I would like to breastfeed:
[ ] As soon as possible after delivery
[ ] Before eye drops/ointment are given
[ ] Later
[ ] Never

I’d like my family members (NAMES):
[ ] To join me and baby immediately after delivery
[ ] To join me and baby in the room later
[ ] Only to see baby in the nursery
[ ] To have unlimited visiting after birth

I’d like baby’s medical exam and procedures:
[ ] Given in my presence
[ ] Given only after we’ve bonded
[ ] Given in my partner’s presence
[ ] To include a heel stick for screening tests beyond the PKU
[ ] To include a hearing screening test
[ ] To include a hepatitis B vaccine

Please don’t give baby:
[ ] Vitamin K
[] Antibiotic eye treatment
[ ] Sugar water
[ ] Formula
[ ] A pacifier

I’d like baby’s first bath given:
[ ] In my presence
[ ] In my partner’s presence
[ ] By me
[ ] By my partner

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I’d like to feed baby:
[ ] Only with breastmilk
[ ] Only with formula
[ ] On demand
[ ] On schedule
[ ] With the help of a lactation specialist

I’d like baby to stay in my room:
[ ] All the time
[ ] During the day
[ ] Only when I’m awake
[ ] Only for feeding
[ ] Only when I request

I’d like my partner:
[ ] To have unlimited visiting
[ ] To sleep in my room

If we have a boy, circumcision should:
[ ] Be performed
[ ] Not be performed
[ ] Be performed later
[ ] Be performed with anesthesia
[ ] Be performed in the presence of me AND/OR my partner

As needed post-delivery, please give me:
[ ] Extra-strength acetaminophen
[ ] Percoset
[ ] Stool softener
[ ] Laxative

After birth, I’d like to stay in the hospital:
[ ] As long as possible
[ ] As briefly as possible

If baby is not well, I’d like:
[ ] My partner and I to accompany it to the NICU or another facility
[ ] To breastfeed or provide pumped breastmilk
[ ] To hold him or her whenever possible