Recommended Birthing Plan

Birth Preferences Worksheet

Keep in mind your birth preferences are guidelines, but labor is unpredictable. At LLU Children’s Hospital, we want to honor your wishes and give you and your family a wonderful experience as you celebrate the birth of your child. We assure you that the health of you and your baby is our highest priority. If this means we cannot follow your birth preferences exactly, we promise to communicate with you and make recommendations based on guidelines developed through evidence-based practice.

Name: Attendant(s)

I would like the following people to be present during labor and/or birth:

Partner:

Friend(s):

Relative(s):

Doula:

Children:

Important things to know about me (cultural, religious preferences, fun facts):

Name of baby (if you have a name chosen):

Amenities

I would like to: q Bring music. q Dim the lights. q Wear my own clothes during labor and delivery. q Take pictures during labor and delivery. q Bring aromatherapy. q Other:

Hospital Admission and Procedures

I would like the option of returning home if I’m not in active labor. Once I’m admitted, I would like: q My partner to be allowed to stay whenever possible. q To wear my contact lenses, as long as I don’t need a cesarean delivery. q To eat if I wish (to be discussed with physician on call and anesthesia). q To stay hydrated by drinking clear fluids and have a saline lock for emergencies. q To walk and move around as I choose. q Other: .

Other Interventions

As long as the baby and I are doing fine, I would like to: q Have intermittent, rather than continuous, electronic fetal monitoring per LLU Children’s Hospital policy (discuss with your healthcare provider). q Be allowed to progress naturally and have my labor augmented only if necessary. q Have wireless fetal monitoring if I am a candidate. q Other:

Labor Props

If available, I would like to try a: q Birthing ball q Peanut ball q Squatting bar

I’d like to bring the following equipment with me:

Pain Relief

I would like to try the following pain-management techniques: q Acupressure. q Shower. q Breathing techniques/distraction. q Hot/cold therapy. q Self-hypnosis. q Massage. q Medication. q Please do not offer me pain medication. I will request it if I need it. q Other:

If I decide I want medicinal pain relief, I would prefer: q Regional analgesia (an epidural and/or spinal block). q Systemic medication.