Our Birth Plan
Complete this form and then hit the submit button.  Your Birth Plan will appear on your screen and you will receive a copy of it in your e-mail box. Please be sure your e-mail address is correct so that your copy can be returned to you.
Name:
My E-mail Address:
My Coach is:
Other Support People will be:
This is what I would like to have during labor: 
(Select any of the following options that apply to your birthing desires)
remain mobile during labor
no shave prep
no routine IV's
no enema (either at home or on site)
to urinate on my own
my partner ALWAYS present
to have low level lighting in the room
to eat and drink during labor
only intermittent fetal monitoring
spontaneous rupture of membranes
pain relief/epidural if I ask
to use various positions
to use aroma therapy
to have massages
to listen to music
to NOT have pitocin
Vaginal Delivery options I would like:
(Select any of the following options that apply to your birthing desires)
no episiotomy
perineal massage
my partner to cut the cord
my partner to bath the baby after birth
the baby on my stomach after bathing
be in the position of my choice
support of my legs by people not stirrups
In the event of a C-Section, I would like the following:
(Select any of the following options that apply to your birthing desires)
my partner in the delivery room
my partner to hold the baby in the delivery room
an epidural if possible
After delivery, I would like the following:
(Select any of the following options that apply to your birthing desires)
breast feed immediately
breastfeed in the recovery room after Cesarean
allow bonding before eye ointment and vitamin K
have our other children visit
The name of my pediatrician is: 
Today's date is: 
 mm/dd/yy
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