Birth Plan-for client SubmitPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Mother's Name *FirstLastPartner's Name *FirstLastEmail *Additional Support (Midwife, Doula, Photographer, Family Member or Friend)Birthing EquipmentBath Tub or showerBirth Ball and peanut ballSquat BarDoula equipment-rebozo, tenz unit, and moreComfort MeasuresLow lightMusicEssential oilsMassageCounter PressurePrayerAffirmationsCold or warm compressClothingHospital gownOwn clothingHydrationIV (required for hospital birth)Continuous Oral FluidsSnacksBring own snacksHospital “clear liquids” dietInduction / Augmentation / InterventionsPitocinAROM (Artificial rupture of membranes)VacuumForcepsC-sectionCatheter (balloon)Cervical checksFentanyl-pain medicationEpidural-pain medicationPain Medication You DO wantPain Medication to AvoidPushing Position to TryDuring DeliveryEpisiotomyTearing naturallyAfter DeliveryImmediate skin to skinBaby in warmer * cleanupChord CuttingImmediatelyDelayed (recommended)Vitamin KDeclineDelayWantErythromicinDeclineDelayWantHep BDeclineDelayWantGolden HourSkin to skinBreastfeeding helpFeedingBreastmilkFormulaDonated BreastmilkRoomingKeep baby in room for ALL examinationsTake baby to nursery for examinations & restWho goes with baby to NICU / Nursery (if necessary)Additional NotesSubmit
EN 
ES