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Visual Birth Plan
Visual Birth Plan
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My name
*
My e-mail address
*
This will be for billing and general communication through your pregnancy and through the postpartum period.
My phone number
*
My partner's phone number
Name of anyone else attending you at your birth and their relation to you
*
Any other legal names that may be used by our birthing place
*
There have been times when I was delayed getting to a client because their hospital had their maiden name instead of their married name on file.
Baby's Name
Estimated Due Date
*
Home Address
This is used for if Abbey will serve you at home before going to the birthing place or if you are having a homebirth.
Birth Place location
Address if you can or a name that Abbey can search for
My Baby: Select and/all you would like represented on your birth plan.
Expecting Twins
I Am Expecting Triplets
Expecting Quadruplets
It's a Boy: Blue
It's a Boy: Green
It's a Boy Black
It's a Girl: Pink
It's a Girl: Yellow
It's a Girl Black
Birthing Location: Select where your birth is planned to take place (If you are choosing a C-section there will be other C-section options further down)
Birth Center
Operating Room Birth
Hospital Birth
Home Birth
My Personal History: Select and/all you would like represented on your birth plan.
Survivor of Abuse: Butterfly
Survivor of Abuse: Sparrow
Survivor of Abuse: Red
Survivor of Abuse
I am at Risk of Postpartum Depression: Red
I am at Risk of Postpartum Depression: Black
I Have PTSD: Black
I Have PTSD: Red
I have PTSD: Branch
I am at Risk of Postpartum Depression: Dandelion
I am in Recovery: Black
I am in Recovery: Red
I am in Recovery: Succulent
I Am in Recovery: Leaves
I Am Coping With Anxiety and Depression
I Am Coping With Anxiety
I Am Coping With Depression
This is My First Baby: Black
This is My First Baby: Gold
This is a Rainbow Baby
This is My Second Baby
This is My Third Baby
I Am an Experienced Birther
Medical History/Needs: Select and/all you would like represented on your birth plan.
Interpreter Needed
Allergy Warning: Black
Allergy Warning: Red
I Have An Important Requirement
I Have a Medical Need Red
I Have A Medical Need: Black
I Have Gestational Diabetes
I Have Blood Pressure Issues
I Received the Husband Stitch at a Previous birth
Tailbone Injury
My Labor and Birth is Planned as.: Select and/all you would like represented on your birth plan.
I Am Choosing a VBAC
C-Section Birth
I Am Choosing Elective C-section
I am Choosing a Repeat C-section
I Am Choosing a Water Birth
I Am Choosing Water Labor
I Am Choosing Water Labor and Birth
Natural Birth
Labor Naturally as Long as I Choose
Medical Management of Labor
Medical Management of Active Labor
Medical Management of Labor and Birth
Hypnobirthing: Please Do Not Interrupt
Care Provider Choices: Select and/all you would like represented on your birth plan.
Midwife Led Unit
OB Led Unit
Ask For My Consent
Hands Off Care Provider
Hands On Care Provider
No Students: Red
No Students: Black
Limited Number of Students
Students Accepted
My Birth Environment: Select and/all you would like represented on your birth plan.
Do Not Disturb
I Want to Wear My Own Clothes
Low Light Levels During Labor and Birth
Quiet Labor and Birth Environment Please
I Have Music I Want Played
I Don't Want Visitors
I Want Family in the Labor and Birth Space
I Want Friends and Family in the Labor Space
I Want Freedom to Move During Labor
I Want Limited Visitors
Essential Oils in Use
No Aromatherapy: Red
No Aromatherapy: Black
Partner With Me at All Times
Please Say
Please Don't Say: Black
Please Don't Say: Red
Spiritual and Cultural Aspects of My Birth: Select if any you would like represented on your birth plan.
I Am Celebrating My Culture in My Labor and Birth
I Am Celebrating my Beliefs in My Labor and Birth
I Am Celebrating My Culture and My Beliefs in My Labor and Birth
Coping Strategy:Select and/all you would like represented on your birth plan.
I Choose an Epidural
Do Not Offer Me an Epidural
I Do Not Want an Epidural: Black
I Do Not Want an Epidural: Red
Do Not Offer Me Medical Pain Management: Red
Do Not Offer Me Medical Pain Management: Black
I Accept the Offer of Pain Management
Eat and Drink During Labor
I Am Comfortable With Physical Touch/Massage
Please Do Not Touch Me Without Asking
I Am Using a TENS Unit
I Am Using Reflexology
I Accept Nitrous Gas
No Nitrous Oxide Gas: Red
No Nitrous Oxide Gas: Black
I Have a Doula
Half Hour Rule
Even if you are planning a medically managed birth Voices of Eve strongly encourages choosing some non-medical coping tools to help you until the medical management is in place, in case it becomes not an option, or in case it fails.
Augmentation Preferences: Select and/all you would like represented on your birth plan.
Accept Breaking Water
Do Not Break My Water
I Want My Water to Break On It's Own
Accept Pitocin Sweep for Induction or Augmentation
No Pitocin: Red
No Pitocin Black
Accept Pumping for Augmentation or Induction
No Pumping for Augmentation or Induction: Black
No Pumping for Augmentation or Induction: Red
No Pumping for Augmentation or Induction: Black
Accept Membrane Sweeping
No Membrane Sweep: Black
No Membrane Sweep: Red
Monitoring: Select and/all you would like represented on your birth plan.
Accept Routine Cervical Checks
Cervical Checks Only on My Request
Don't Ask to Check My Cervix: Black
Don't Ask to Check My Cervix: Red
I Can Check My Own Cervix
Limited Cervical Checks
No Cervical Checks: Red
No Cervical Checks: Black
I Accept an IV
IV or Saline Lock in Right Hand
IV or Saline Lock in Left Hand
No IV or Saline Lock: Black
No IV or Saline Lock: Red
I Accept Constant Fetal monitoring
I Do Not Accept Constant Fetal monitoring: Black
I Do Not Accept Constant Fetal monitoring: Red
I Choose Intermittent Monitoring
No Fetal Scalp Monitor: Black
No Fetal Scalp Monitor: Red
Pushing Choices: Select and/all you would like represented on your birth plan.
Choose My Own Birthing Position
Care Provider Catch the Baby
______ Catch the Baby (Other family member, friend, doula, etc)
Dad Wants to Catch Our Baby
I Want to Catch My Baby
Dad Wants to Catch Our Baby
Accept Assisted Delivery When Needed
Don't Tell Us the Sex: Color
Don't Tell Us the Sex: Black
Don't Tell Me the Sex: Color
Don't Tell Me the Sex: Color
Don't Tell Me When to Push: Black
Don't Tell Me When to Push: Red
I Want a Mirror to Watch My Baby's Birth
I don't Want to Touch My Baby's Head as it Crowns: Black
I don't Want to Touch My Baby's Head as it Crowns: Red
I Want to Touch My Baby's Head as it Crowns
No Episiotomy: Red
No Episiotomy: Black
Placenta Choices: Select and/all you would like represented on your birth plan.
Partner to Cut the Cord
I Want to Cut My Cord
Care Provider Cut the Cord
_________ to Cut the Cord
Delayed Cord Clamping for 3 Minutes
Delay Cord Clamping for 15 Minutes
Delay Cord Clamping Until Cord Turns White
Active Management
Physiological 3rd Stage
Donating Cord Blood
I Want to See My Placenta
I don't want to see my placenta: Black
I don't want to see my placenta: Red
I Am Keeping My Placenta
Delayed Active Management
Lotus Birth
First Hour: Select and/all you would like represented on your birth plan.
Breastfeeding as Soon as Possible
Immediate Skin to Skin and Breastfeeding Are Important to Me
Delay Newborn Exams for Bonding
Quiet Postpartum Environment
Calm and Dimly Lit the First 1-2 Hours
Designated Person with Newborn at All Times
Partner With Me At All Times
I Accept Postpartum Pitocin
I Do Not Accept Postpartum Pitocin: Red
I Do Not Accept Postpartum Pitocin: Black
Medical management of 4th Stage
Natural Postpartum
Please Wipe My Baby
Please Don't Wipe My Baby: Black
Please Don't Wipe My Baby: Red
My choices for my baby: Select and/all you would like represented on your birth plan.
Accept Vitamin K Injection
No to Vitamin K: Black
No to Vitamin K: Red
Prefer Oral Vitamin K
Accept Newborn Blood Sampling
No Newborn Blood Sampling: Red
Accept Hepatitis B Injection: Black
Accept Hepatitis B Injection: Red
No to Hepatitis B Injection: Black
Accept All Vaccinations
Delay Vaccinations
No to All Vaccinations
Accept Eye Ointment
No Eye Ointment: Red
No Eye Ointment: Black
I Am Choosing to Formula Feed
I Am Breastfeeding
Do Not Give My Baby Donor Milk: Red
Do Not Give My Baby Donor Milk: Red
DO Not Give My Baby Donor Milk: Black
I Accept Donor Milk
Accept Circumcision
Do Not Accept Circumcision: Black
Do Not Accept Circumcision: Red
Do Not Give My Baby Formula
I Am Choosing to Formula Feed
Do Not Offer My Baby a Pacifier: Red
Do Not Offer My Baby a Pacifier: Black
Please Wash My Baby
Please Don't Wash My Baby: Black
Please Don't Wash My Baby: Red
Choices in the event of a C-section or Choosing a C-section: Select and/all you would like represented on your birth plan.:
Talk me through what is happening
Don't talk me through what is happening: Black
Don't talk me through what is happening: Red
Privacy While the Catheter is Inserted
Immediate Skin to skin
Gentle C-section
Drape so I Can't See
No Drape So I Can See
I Want to Help Deliver My Baby
Blank to be filled in later:
Blank: to be filled in later
Fill in the box below what you would like put in this blank icon. Note also if you have more than one.
Any other specific preferences I have that is not on this list, or other clarifications, notes, concerns, et.
Abbey might be able to create a visual option if there is something else that you want specifically adress that is not already on the list.
What do you most desire for Abbey's role as your doula
*
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