The Bump Birth Plan

TheBump.
com
birth plan
Use this easy fill-in-the-blank birth plan to prepare yourself for delivery and communicate your wants and needs
to your medical team.
Full name:
Partners name:
Todays date:
Due date/Induction date:
Doctors name:
Hospital name:
Please note that I:
My delivery is planned as:
Have group B strep
Vaginal
Am Rh incompatibility with baby
C-section
Have gestational diabetes
Water birth
VBAC
Id like...
Partner:
Parents:
Other children:
Doula:
Other:
...present before AND/OR during labor
During labor Id like...

Music played (I will provide)
To wear my own clothes
The lights dimmed
To wear my contact lens the entire time
The room as quiet as possible
My partner to film AND/OR take pictures
As few interruptions as possible
My partner to be present the entire time
As few vaginal exams as possible
To stay hydrated with clear liquids & ice chips
Hospital staff limited to my own doctor

and nurses (no students, residents or
interns present)
To eat and drink as approved by my doctor
Page 1 of 6
TheBump.com
birth plan
Id like to spend the first stage of labor:
Im not interested in:
Standing up
An enema
Lying down
Shaving of my pubic area
Walking around
A urinary catheter
In the shower
An IV, unless Im dehydrated (and a

heparin or saline lock IS/IS NOT okay)
In the bathub
Id like fetal monitoring to be:

Continuous
External
Intermittent
Performed only by Doppler
Internal
Performed only if the baby is in distress
Id like labor augmentation:

Performed only if baby is in distress
Performed with Pitocin
First attempted by natural methods such

as nipple stimulation
Performed by rupture of the membrane
Performed by membrane stripping

Performed with prostaglandin gel
Performed by stripping of the membrane

Never to include an artificial rupture of
the membrane
For pain relief Id like to use:

Acupressure
Meditation
Acupuncture
Reflexology
Breathing techniques
Standard epidural
Cold therapy
TENS
Demerol
Walking epidural
Distraction
Nothing
Hot therapy
Only what I request at the time
Hypnosis
Whatever is suggested at the time
Massage
Page 2 of 6
TheBump.com
birth plan
During delivery I would like to:
Squat
Use people for leg support
Semi-recline
Use foot pedals for support
Lie on my side
Use birth bar for support
Be on my hands and knees
Use a birthing stool
Stand
Be in a birthing tub
Lean on my partner
Be in the shower
I will bring a:
Birthing stool
Squattng bar
Birthing chair
Birthing tub
As the baby is delivered, I would like to:

Push spontaneously
Avoid forceps usage
Push as directed
Avoid vacuum extraction
Push without time limits, as long as the

baby and I are not at risk
Use whatever methods my doctor

deems necessary
Use a mirror to see the baby crown
Help catch the baby
Touch the head as it crowns
Let my partner catch the baby
Let the epidural wear off while pushing
Let my partner suction the baby
Have a full dose of epidural
I would like an episiotomy:

Used only after perineal massage, warm
compresses and positioning
Rather than risk a tear
Not performed, even if it means risking
a tear
Performed as my doctor deems necessary

Performed with local anesthesia
Performed by pressure, without local anesthesia
Followed by local anesthesia for the repair
Performed only as a last resort
Page 3 of 6
TheBump.com
birth plan
Immediately after delivery, I would like:
My partner to cut the umbilical cord
The umbilical cord to be cut only after it
stops pulsating
To bank the cord blood
To deliver the placenta spontaneously and

without assistance
To see the placenta before it is discarded
Not to be given Pitocin/oxytocin
To donate the cord blood
If a C-section is necessary, I would like:

A second opinion
My hands left free so I can touch the baby
To make sure all other options have been

exhausted
The surgery explained as it happens
To stay conscious
My partner to remain with me the entire
time
An epidural for anesthesia

My partner to hold the baby as soon as possible
To breastfeed in the recovery room
The screen lowered so I can watch baby

come out
I would like to hold baby:
I would like to breastfeed:
Immediately after delivery
As soon as possible after delivery
After suctioning
Before eye drops/ointment are given
After weighing
Later
After being wiped clean and swaddled
Never
Before eye drops/ointment are given
I would like my family members:

(names:)
To join me and baby immediately after

delivery
Only to see baby in the nursery

To have unlimited visiting after birth
To join me and baby in the room later
Page 4 of 6
TheBump.com
birth plan
I would like babys medical exam & procedures:
Please dont give baby:
Given in my presence
Vitamin K
Given only after weve bonded
Antibiotic eye treatment
Given in my partners presence
Sugar water
To include a heel stick for screening tests

beyond the PKU
Formula
A pacifier
To include a hearing screening test

To include a hepatitis B vaccine
Id like babys first bath given:
Id like to feed baby:
In my presence
Only with breastmilk
In my partners presence
Only with formula
By me
On demand
By my partner
On schedule
With the help of a lactation specialist
Id like baby to stay in my room:
Id like my partner:
All the time
To have unlimited visiting
During the day
To sleep in my room
Only when Im awake

Only for feeding
Only when I request
If we have a boy, a circumcision should:

Be performed
Be performed with anesthesia
Not be performed
Be performed in the presence of me

AND/OR my partner
Be performed later
Page 5 of 6
TheBump.com
birth plan
As needed post-delivery, please give me:
After birth, Id like to stay in the hospital:
Extra-strength acetaminophen
As long as possible
Percoset
As briefly as possible
Stool softener
Laxative
If baby is not well, Id like:

My partner and I to accompany it to the
NICU or another facility
To breastfeed or provide pumped
breastmilk
To hold him or her whenever possible
Page 6 of 6

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What options does the birth plan provide for pain relief during labor?

What options does the birth plan provide for pain relief during labor?

What are the options provided for holding the baby immediately after birth?

What are the options provided for holding the baby immediately after birth?

TheBump.

Due date/Induction date:

Please note that I:

My delivery is planned as:

Have group B strep

Am Rh incompatibility with baby

Have gestational diabetes

...present before AND/OR during labor

During labor Id like...

To wear my own clothes

The lights dimmed

To wear my contact lens the entire time

The room as quiet as possible

My partner to film AND/OR take pictures

As few interruptions as possible

My partner to be present the entire time

As few vaginal exams as possible

To stay hydrated with clear liquids & ice chips

Hospital staff limited to my own doctor

To eat and drink as approved by my doctor

Im not interested in:

Shaving of my pubic area

An IV, unless Im dehydrated (and a

Id like fetal monitoring to be:

Performed only by Doppler

Performed only if the baby is in distress

Id like labor augmentation:

Performed with Pitocin

First attempted by natural methods such

Performed by rupture of the membrane

Performed by membrane stripping

Performed by stripping of the membrane

For pain relief Id like to use:

Only what I request at the time

Whatever is suggested at the time

Use people for leg support

Use foot pedals for support

Use birth bar for support

Be on my hands and knees

Use a birthing stool

As the baby is delivered, I would like to:

Avoid forceps usage

Avoid vacuum extraction

Push without time limits, as long as the

Use whatever methods my doctor

Use a mirror to see the baby crown

Help catch the baby

Touch the head as it crowns

Let my partner catch the baby

Let the epidural wear off while pushing

Let my partner suction the baby

Have a full dose of epidural

I would like an episiotomy:

Performed as my doctor deems necessary

Performed only as a last resort