Create Your Birth Plan Name* First Last Date of Birth* MM DD YYYY Doctor*We are excited to be able to share your upcoming birth experience with you. To help make your experience comfortable, please let us know your wishes and desires. Please check your preferences below. Feel free to list additional ideas of what you would like and we will try to meet your wishes as best we can.LaborChoose as many as you would like Besides my coach, I wish to have additional support people present during my labor and delivery. I wish to have one of my support people take pictures and videotape. I would like to be free to walk around during labor. I wish to be able to move around and change position at will throughout labor. I would like to be able to have fluids by mouth throughout the first stage of labor. I would like the environment to be kept as quiet as possible. I would like to bring my own music to play during labor. I would like the lights in my room to be kept low during my labor. Other Monitoring I would like to be monitored as the nurses and doctors recommend. I would like to be monitored as little as possible. Other: Labor Augmentation/ Induction I do not wish to have my amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring. If labor is not progressing, I would like to have my amniotic membrane ruptured before other methods are used to augment labor. I would prefer to be allowed to try changing positions and other natural methods such as walking before other medications are administered. Other: Anesthesia/ Pain Medications(including IV pain medications & epidural) I would like to deliver without the use of pain medications. I will ask for pain medications if I need them. I would like to use nitrous oxide, which is a minimal intervention option. Before considering an epidural, and if the situation warrants, I would like to try IV pain medications. I would like to have an epidural. Other: Cesarean Section Unless absolutely necessary, I would like to avoid a Cesarean section. If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making process. I would like to use a clear drape during my Cesarean section to be able to see the birth of my baby. If my baby is not in distress, I would like to have my baby placed on my chest after delivery. I would like to have a delayed cord clamping. Other: Delivery I would like to be allowed to choose the position I give birth in. I would like to try a Water Birth in a birthing tub. I would like my coach and/or nurses to support me and help support my legs as necessary during the pushing stage. I would like a mirror to view my baby being born. I would like the chance to touch my baby’s head when it crowns. Even if I am fully dilated, and assuming my baby is not in distress, I would like to try and wait until I feel the urge to push before beginning the pushing phase. I would like to have my baby placed on my stomach/chest immediately after delivery. I would like to have a delayed cord clamping. Other: Immediately After Delivery I would like to have my coach cut the cord. My coach does not wish to cut the cord. If my baby is not in distress, I would like to breastfeed right after delivery, before any medical procedures are done (medications, weight). If my baby must be taken from me to receive medical treatment, I would like my coach or some other person I designate to accompany my baby at all times. I would prefer to hold my baby for warmth rather than have him/her placed under heat lamps. I would like to see the placenta after delivery. Other: Postpartum Unless required for medical reasons, I do not wish to be separated from my baby. I would like to have my baby room in and be with me at all times. Other: Breastfeeding I plan to breastfeed my baby and would like to begin nursing very shortly after birth. Unless medically necessary, I do not wish to have any bottles given to my baby. I do not want my baby to be given a pacifier. I do not plan to breastfeed my baby. Other: Circumcision I do not wish to have my baby circumcised. I would like to have my baby circumcised before we leave the hospital. I would like my baby circumcised in the clinic after discharge. Other information you would like us to knowCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.