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Genesis Birth Concepts Birth Plan Guide
Let's Have A Baby!
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First name
*
Last name
*
Email
*
Phone
*
Address
Birthday
Month
Expected Due Date
*
Month
Name of Primary Support Person
*
Relationship of Support Person
Name of Physician/ Certified Nurse Midwife
*
My Delivery Is Planned As:
*
Natural Childbirth
Water Birth
I Would Like To Wear;
Hospital Gown
My Own Clothes
For Comfort Measures During Labor, I Would Like To:
Walk In The Room/Hall
Use The Birthing Ball
Use Heat/ Cold Massage
Use Water Therapy
Use My Own Pillows
Have Clear Liquids (Water, Juice, Jello)
Use Shower
Use Squat Bar
Sit In Rocker
For Pain Control
During The Pushing Phase of Labor, I Would Like To:
Use Foot Pedals
Use The Stirrups
Use The Squat Bar
Use Whatever Method Is Comfortable At That Time
For Intravenous Access I Would Prefer:
That upon admission, routine lab work will be drawn and at that time, tubing will remain in place and a saline lock created.
If an IV must be connected, I do not want any pain medications administered through the IV without permission from me or my significant other.
To be kept informed at all times regarding IV fluids I am receiving, medications, and their purpose.
During Birth:
I want to see the baby's head (in a mirror) as it crowns
I want to touch the baby's head as it crowns.
I want my partner to help catch the baby (if appropriate).
Immediately After The Deliver, I Would Like To:
Place baby skin-to-skin
Wrap baby in blanket before holding.
Breastfeed my baby within the first hour
Have my significant other cut the cord
Have my baby's first bath in my room.
Feeding:
I plan to breastfeed
Please assist me with nursing as soon as possible after the birth.
Please no supplemental formula to my baby without my permission.
I plan to bottle feed my baby
If I Have A Boy, I Would Like For Him To Be Circumcised
Yes
No
I Plan to Attend, or Have Already Attended, These Classes During This Pregnancy
Early Pregnancy
Baby Basics
Basic Training For New Dads
Breastfeeding Basics
Childbirth Preparation
What is the best and/or worst thing about your previous labor and birth? Or other comments:
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