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Birth Plan Worksheet  

This Birth Plan Worksheet is designed for use by expectant parents all over the United States. It has a variety of options listed to stimulate research regarding what is available in your community. It is not designed to be printed in its entirity, rather to be used to discuss options with your careprovider.

Need one to print? Click here to print a Birth Worksheet to take to you care provider once you have completed this worksheet!

Birth Place
Hospital Labor & Delivery Area
Birthing Room (LDR or LDRP) Birthing Center

Care Provider
Physician Obstetrician
Family Practice Physician Midwife
Certified Nurse Midwife Lay Midwife

Childbirth Education
Classes at the Hospital Independent Educator
Educator affiliated with physician Lamaze method
Bradley method ICEA
Hypnosis/Hypnobirthing other

Types of Classes
Childbirth Preparation Breastfeeding
Parenting Child Care
Infant/child CPR Sibling Preparation
VBAC (vaginal birth after a cesarean) Cesarean
Teen Childbirth Preparation Teen Breastfeeding

Pregnancy/Birth Support
Husband/partner Sibling of baby
Family members (how many?)_____ Friends
Certified doula/labor support professional  

Oral fluids IV
Saline/Heparin Lock Perineal shave

Comfort Measures
Upright positioning Hydrotherapy (labor tub or shower)
Massage/effleurage Music Therapy
Aromatherapy Breathing Techniques
Active relaxation techniques Heat/cold therapy
Therapeutic touch Reiki
Guided Imagery Acupressure
Squatting Hands/knees position
Birthing Ball  

Assessment of Baby via Heart Beat
Intermittent Auscultation with Stethoscope of Baby's Heart Beat

Electronic Fetal Monitoring



IUPC (intrauterine pressure catheter)

None Relaxants
Local infiltration Regional anesthetics
Epidural Spinal
Paracervical Pudendal
Spinal Narcotic Walking Epidural

None Cervical Ripening Gel
Pitocin Amniotomy
Stripping of Membranes Foley Catheter
Laminaria Tents  

Birth Positions
Squat/using squat bar Hands/knees
Semi-sitting or "C" Sidelying
Sitting with feet in stirrup supports  Birthing stool

Forceps Vaccum Extraction
Perineal Massage (no or minimal episiotomy) Episiotomy

Immediately after birth
Partner cut cord Leboyer birth
Immediate skin-to-skin on mother's abdomen Bonding - skin-to-skin
Breastfeeding Delay of eye ointment

During hospital stay
Rooming-in Breastfeeding
Breastfeeding without bottles, nipples or pacifiers Breast/bottlefeeding
Bottlefeeding Visit from Lactation Consultant
Circumcision Sibling visitation

Going Home
Parent Answer Line Home Care Visit
Lactation Consultant Visit LaLeche League Information

Husband/partner support Husband/partner present during procedure
Anesthesia Options Parent bonding afterwards
Breastfeeding immediately after

Peanut Ball

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Peanut Ball

Also known as the Physio-Ball, this increases stability during labor!

Item in stock!
Birthing Balls

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Birthing Balls

Over 100 hospitals use our medical-grade physio-therapy birth balls!

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The Birth Ball Source Book

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The Birth Ball Source Book

Do you need an up-to-date book about how to use a birth ball?

Our Price: $$6.95

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Childbirth Educator Office CD-ROM

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Childbirth Educator Office CD-ROM

Essential forms + curriculum for your childbirth education business with over 50 handouts!

Our Price: $$29.95

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Please feel free to look around, read our disclaimer, and check out the links to other related sites. If you have any questions, send us a message.

We will reply as soon as possible. Funding for this site is provided solely by Perinatal Education Associates, Inc. Perinatal Education Associates, Inc. undertake to honor or exceed the legal requirements of medical/health information privacy that apply in the State and Country where this website is located. All content is written by the owners of the site unless otherwise noted.

Privacy Policy: Perinatal Education Associates, Inc. does not record or maintain any information, confidential or otherwise, in any database. No names, email addresses or other data is retained. This website does not use cookies. The site undertakes to honor or exceed the legal requirements for medical/health information privacy worldwide.

All articles appearing on www.birthsource.com were written by the founder/President of Perinatal Education Associates, Inc unless otherwise noted. The information on www.birthsource.com is copyrighted. Unauthorized use of the exact content will be met with legal action. To obtain permission to use this information, please contact info@birthsource.com.

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