One Page Birth Plan
One Page Birth Plan
Prepared by: [YOUR NAME]
Contact Email: [YOUR EMAIL]
I. Personal Information
|
Parent Details |
|
|---|---|
|
Name |
[PARENT'S FULL NAME] |
|
Partner’s Name |
[PARTNER'S FULL NAME] |
|
Due Date |
[DUE DATE] |
|
Obstetrician/Midwife |
[OBSTETRICIAN/MIDWIFE'S NAME] |
|
Birth Location |
[HOSPITAL/BIRTH CENTER/HOME] |
II. Labor Preferences
A. Environment
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Lighting Preferences: Dim / Natural Light / Bright
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Sound Preferences: Silence / Music / White Noise
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People Present: Partner, Doula, Family Members, Friends (Specify Names)
B. Pain Management
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Preferred Methods:
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Breathing Techniques
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Hypnobirthing
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Epidural
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IV Pain Medication
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Nitrous Oxide
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Other: [SPECIFY OTHER METHODS]
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C. Movement and Positioning
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Freedom to Move: Yes / No
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Preferred Positions: Walking, Squatting, Sitting, Birthing Ball, Hands and Knees
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Use of Birthing Aids: Birthing Ball, Squat Bar, Other: [SPECIFY OTHER AIDS]
III. Delivery Preferences
A. Pushing
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Pushing Preferences: Spontaneous / Directed
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Use of Mirror: Yes / No
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Episiotomy: Prefer to avoid if possible / Acceptable if necessary
B. Interventions
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Induction Methods: Natural methods preferred / Medical induction if necessary
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Assisted Delivery: Avoid if possible / Use Forceps / Vacuum Extraction if necessary
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Cesarean: Avoid if possible / Planned / Open to C-Section if medically indicated
C. Immediate Post-Birth
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Skin-to-Skin Contact: Immediate / After Initial Cleaning
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Umbilical Cord: Delayed Clamping / Immediate Clamping
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Cord Blood Banking: Yes / No / Undecided
IV. Postpartum Care
A. Baby Care
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Feeding Preferences: Breastfeeding / Formula / Combination
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Rooming-In: Yes / No / Partial
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Pediatrician: [PEDIATRICIAN’S NAME]
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Vaccinations: Follow Standard Schedule / Selective / Delayed
B. Parent Care
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Pain Relief: Request options / Minimal pain relief preferred
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Visitation: Open to visitors / Limited visitation / No visitors
V. Special Considerations
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Religious or Cultural Preferences: [SPECIFY RELIGIOUS]
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Allergies or Medical Conditions: [LIST ANY KNOWN ALLERGIES]
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Other Important Information: [ANY OTHER IMPORTANT INFORMATION]
VI. Conclusion
We appreciate your attention to our birth plan and your commitment to supporting us during this significant time. Your understanding and cooperation in adhering to our preferences contribute to creating a positive and safe birth experience for both us and our baby. If there are any questions or concerns, please feel free to reach out to us.
Thank you for respecting our birth plan and supporting us through this special time. Our goal is a safe and positive birth experience for both the baby and the parents.
