Medical Staff

• The labor and delivery shall be supervised by:

  • a doctor
  • a midwife

• Indicate the full name of a midwife:

• Indicate the full name of a doctor:

• Indicate the name and type of a medical facility where labor and delivery shall take place:

• Does the birth parent want her doula to be present during labor or delivery?

  • No
  • Yes

• Indicate the full name of a doula:

Labor

• Select the planned type of the birth:

  Choose option vaginal delivery (unmedicated) caesarean section (C-section) water birth assisted vaginal birth (forceps or vacuum) vaginal delivery (medicated)

• Select position in which the birth parent wants to be at the first stage of labor:

  Choose option walking standing side-lying hands and knees squatting water immersion leaning forward (over a person or object) using a birthing ball

• Does the birth parent want labor augmentation?

  • Yes
  • No

  !

  Labor augmentation is the use of medical methods to strengthen, speed up, or improve labor contractions after labor has already started.

• Does the birth parent want to be given pitocin to progress the labor?

  • Yes
  • No

• Does the birth parent want medical team to rupture or strip the membranes to progress labor?

  • Yes
  • No

  !

  Rupturing the membranes means a healthcare provider intentionally breaks the amniotic sac to encourage stronger or faster contractions.

  Stripping the membranes means a provider sweeps a finger between the amniotic sac and the uterine wall during a cervical exam to help trigger labor hormones.

• Select the pain relief option the birth parents wants to have during the labor:

  Choose option Epidural anesthesia Spinal block Nitrous oxide (“laughing gas”) Acupuncture or acupressure Massage Hydrotherapy

• List all additional preferences or requests the birth parent wants to say about the labor:

  !

  Requests may include:

  – playing specific music;
  – have the room as quiet as possible;
  – wear my own clothes;
  – have as few vaginal exams as possible etc.

Delivery

• Select the position in which the birth parent want to deliver:

  Choose option squatting lying on back with legs in stirrups hands and knees side-lying standing kneeling water birth using a birth stool or chair

• Does the birth parent want to be coached on when to push?

  • Yes
  • No

• Does the birth parent want to see the baby crown?

  • Yes
  • No

• Does the birth parent want photos to be taken during the labor?

  • Yes
  • No

• In case of an emergency C-section (caesarean birth), list all the preferences or requests the birth parent has:

• Select who shall cut the baby's umbilical cord:

  Choose option birth parent partner doula midwife doctor

• Does the birth parent want to bank the cord blood?

  • Yes
  • No

• Does the birth parent want for the placenta to be saved for later use?

  • Yes
  • No

Baby Medical Procedures

• The baby's medical examination shall be performed:

  Choose option after I have had a chance to bond with the baby before the bonding with the baby

• List all the baby's medical exams to which the birth parent give consent to:

• Shall the baby to be circumcised as soon as possible after birth?

  • No
  • Yes

• Does the birth parent want to be present during the circumcision procedure?

  • No
  • Yes

After Delivery

• Does the birth parent plan to breastfeed?

  • No
  • Yes

• Describe all breastfeeding preferences the birth parent has:

• After the delivery the baby shall stay:

  • all the time with the birth parent
  • only during certain hours with the birth parent

• Indicate the schedule when baby could stay with the birth parent after the delivery:

• When does the birth parent allow visitors (e.g., friends or family) to come after the delivery?

  • immediately after
  • only upon a separate birth parent's request

• Does the birth parent have a living will or heath care power of attorney?

  • No
  • Yes

  !

  In the context of a birth plan, a living will for the birth parent is a document that states their healthcare preferences in case they cannot make decisions during labor, delivery, or postpartum care.

• Do you want to add a signature?

  • Yes
  • No

• Birth Parent signature:

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