Table 1.

Standardized Birth Plan

My supportive person's first name: ____________________

For each statement, please choose ALL options that you would like.

While in labor, I would like: ___ Music playing with speakers that I provide ___ The TV playing ___ A quiet room ___ My support person to be present and be able to stay with me ___ To stay hydrated with clear liquids and ice chips

I would like to spend the early part of labor ___ Walking ___ Lying down ___ Take a shower

For pain relief, I would like to use ___ Breathing techniques ___ Visualization techniques ___ Meditation ___ Massage, as provided by my support person ___ Epidural ___ Local anesthetic at time of delivery (pudendal block) ___ I am not sure but will request what I would like at the time

As the baby delivers, I would like to ___ Push as directed by medical staff ___ Push when I feel like pushing ___ The labor room to be quiet ___ Use a mirror to see the baby deliver ___ To touch the baby's head as it crowns ___ To avoid episiotomy (a small cut of the outer vagina to make more room for baby) unless my doctor deems it necessary ___ To avoid operative delivery (forceps or vacuum to help the baby deliver) unless my doctor deems it necessary

Immediately after vaginal delivery, I would like: ___ The baby to be placed on my chest ___ The baby to be cleaned and swaddled before given to me ___ My support person to cut the umbilical cord ___ The umbilical cord to be cut after it stops pulsing, unless it is necessary for it to be cut sooner for the well-being of the baby. ___ To donate cord blood to the Hawai‘i Cord Blood Bank ___ To see the placenta before it is discarded ___ To take the placenta home with me

If a Cesarean section is necessary, I would like ___ My support person to be present ___ My support person to hold the baby as soon as possible ___ My support person to accompany the baby to the nursery ___ To see the baby before it is taken to the nursery ___ To have the pediatric team update me before taking the baby from the operating room

I would like to breastfeed ___ As soon as possible after delivery ___ After the baby is cleaned and swaddled ___ I am not sure if I will breastfeed my baby ___ I am interested in seeing the lactation consultant while I am in the hospital ___ I would only like to feed my baby formula if recommended by the pediatricians ___ I would like access to a breast pump