Our interactive worksheet below is a four-step exercise to help you create a list of birth preferences. Because so much depends on your doctor or midwife, where you decide to deliver (hospital, birth center, or home), and even where you live (urban, suburban, or rural area), you might want to do some research to find out what's possible -- and what isn't -- before you begin the worksheet.

Once you fill it out, take the list with you to your next appointment and go over it with your provider. Then come back to the worksheet and enter any modifications you and your provider have agreed on. The result is the final birth plan you'll take with you on delivery day.

1) Fill out the Birth Plan Worksheet. Click any box that applies; you can click as many boxes as you wish. Skip items that aren't important to you or that don't apply to your situation. (Remember, you don't want to overwhelm your provider, so fewer items may be easier for both of you to handle.) Press Clear to start over.

2) Print out the list if you're satisfied, or go back to make any changes. This is the sheet you'll take with you to your next checkup.

3) After you've discussed the plan with your provider, return to the Birth Plan Worksheet. This time, make your selections based on your discussion. Fill out the Identifying Information boxes and choose or rewrite an Opening Paragraph. Once you've finished.

4) Print out your final plan, make three copies, and have your provider or birth attendant sign them. Give one copy to her, have one put in your file at your designated place of birth, and put one in the bag you're packing for your baby's birthday.

Birth Plan Worksheet

ENVIRONMENT

1. I would like to give birth:
    a. in a birthing room.
    b. at home.

2. I would like the following people to be present at the birth (check all that apply):
    a. Partner:  
    b. Friend/s:  
    c. Relative/s:  
    d. Doula:  
    e. Sibling/s:  

 3. I would like to bring music.

 4. I would like the lights dimmed.

 5. I would like to wear my own clothes during labor and delivery.

 6. We would like to film and/or photograph in the delivery room.

 7. I would also like the following amenities (for example: a VCR, a stereo, flowers, etc.): .

PREP

8. About enemas:
    a. I would like to have one upon being admitted.
    b. I would prefer not to have a routine enema.

 9. I would like to wear contact lenses as long as I don't undergo anesthesia.

FIRST-STAGE LABOR

 10. I would prefer not to be separated from my partner at any point during labor or birth.

 11. I would like the option to return home if I'm less than five centimeters dilated.

 12. If my water breaks at the onset of labor, I would prefer to wait at least 6 to 12 hours before inducing, if my and my baby's condition permits.

 13. If I go past my estimated due date, I would prefer not to induce labor as long as the baby and I are fine.

14. If inducing or augmenting labor becomes necessary, I would like to try the following techniques (check all that apply):
    a. Pitocin (oxytocin, syntocinon)
    b. Stripping or breaking membranes
    c. Acupuncture
    d. Castor oil
    e. Herbs (blue and black cohosh)
    f. Breast stimulation/thumb sucking
    g. Enema
    h. Walking
    i. Sexual intercourse

 15. I would prefer not to undergo internal exams during labor unless they're medically necessary.

 16. I would like to eat and drink during labor.

 17. I would like to stay hydrated by drinking clear fluids and using ice chips.

 18. If I need an IV, I would like to use a heparin or saline lock.

19. I'm interested in pain medication only if:
    a. I'm too uncomfortable to handle the pain.
    b. I request it. I do not want pain medication offered to me.

20. I would like to handle pain in the following ways (check all that apply):
    a. Acupressure
    b. Acupuncture
    c. Massage
    d. Hypnosis
    e. Relaxation
    f. Breathing techniques/distraction
    g. Hot/cold therapy
    h. Bath/shower
    i. If bath or shower: I would like my partner to join me.
    j. Medication

21. If I use drugs, I would prefer to use:
    a. Regional or local analgesia or anesthesia
    b. Sedatives and hypnotics
    c. Tranquilizers
    d. Narcotics

22. I would like to be free to walk and move around as I choose during labor.

23. I would like the baby to be monitored:
    a. Externally
    b. Intermittently using a Doppler
    c. Intermittently using a fetoscope

 24. As long as the baby and I are fine, I would like to be free of time limits and not have my labor augmented.

SECOND-STAGE LABOR

25. About episiotomies:
    a. I would prefer to get an episiotomy if I'll risk tearing otherwise.
    b. I would rather risk a tear than have an episiotomy.
    c. Unless I'm having a medical emergency, I would prefer not to have an episiotomy offered to me.

 26. If I need an episiotomy, I would like it to be a pressure episiotomy.

27. I would like to try the following positions for delivery (check all that apply):
    a. Classic/Semi-recline
    b. Side-lying position
    c. Squatting
    d. Hands and knees
    e. Standing upright
    f. Whatever feels right at the time

28. I would like to have the following birthing equipment made available to me (check all that apply).
    a. Birthing bed
    b. Birthing stool
    c. Birthing chair
    d. Beanbag chair
    e. Squatting bar
    f. Birthing pool/tub

29. I would like to bring the following birthing equipment with me (check all that apply):
    a. Birthing stool
    b. Beanbag chair
    c. Birthing pool/tub
    d. Other 

 30. I would like to view the birth using a mirror.

 31. I would like to touch my baby's head as it crowns.

 32. I do not want residents or students to be present during the birth.

 33. I would like to push instinctively and not be told how or when to push.

 34. As long as the baby and I are fine, I would like to be free of time limits on pushing.

35. If an assisted birth becomes medically necessary:
    a. I would prefer the use of forceps.
    b. I would prefer vacuum extraction.

CESAREAN SECTIONS

 36. I would like my partner to be present at all times during the operation.

 37. I would like to be conscious.

 38. I would like the screen lowered so I can see the baby coming out.

 39. I would like to have one hand free to touch the baby.

 40. We would like to videotape and/or photograph the operation and baby coming out.

 41. I would like to have immediate contact with the baby (if the baby is in good health).

POST-BIRTH

 42. My partner would like to catch our baby.

 43. I would like to hold my baby immediately after birth.

 44. My partner would like to suction the baby.

 45. I would like to wait until the umbilical cord stops pulsating before it's clamped and cut.

 46. My partner would like to cut the umbilical cord.

 47. I would like to deliver the placenta unassisted.

 48. I would prefer not to have routine pitocin after the birth.

 49. I would like to postpone newborn procedures until I have had a chance to bond with my baby.

 50. I would like all newborn procedures to take place in my presence.

 51. If I can't be with my baby for newborn procedures, my partner would like to stay with the baby at all times.

52. I plan to:
    a. Breastfeed my baby.
    b. If breastfeed: I would like to breastfeed my baby immediately following the birth.
    c. Formula-feed my baby.

53. The following pacifiers can be offered to my baby (choose all that apply):
    a. Formula
    b. Sugar water
    c. Pacifier
    d. I would prefer that nothing be offered to my baby at any point.

54. I would like my baby fed:
    a. On demand.
    b. On a schedule.

55. As far as contact with my baby goes, I would like:
    a. 24-hour rooming-in with my baby.
    b. My baby to room-in with me only when I'm awake.
    c. My baby brought to me for feedings only.

56. If my baby's a boy:
    a. I would like him circumcised.
    b. I don't want him circumcised.

57.  a. I would like to stay in a private room.
     b. If so: I would like my partner to spend the night with me.

58. I would like my hospital stay to be:
    a. As long as possible
    b. As short as possible

 59. I would like my older child/ren to visit me and my baby.

Final Birth Plan information only:

IDENTIFYING INFORMATION
Name:  
Partner's name:  
Today's date:  
Birth attendant's name:  
Name of Birth Facility:  

OPENING PARAGRAPH
You may want an opening statement about your birth plan philosophy. Choose one of the samples below or click on the text and rewrite to suit your needs. You can also add any preferences not included in the worksheet above. If you don't want an opening paragraph, leave both boxes unchecked.

  Following is a statement of our childbirth desires. We have educated ourselves prior to making these choices and feel that we are prepared to follow through on them. We understand that complications do arise and in such instances trust [physician/midwife] to make necessary decisions. We greatly appreciate your cooperation in realizing our plan.

  It is our desire to have a natural, medication- and intervention-free childbirth. We have educated ourselves and are prepared for the work involved. We understand that complications do arise and in such instances ask that [physician/midwife] discuss with us any procedures or medications before administering them, whenever possible. We greatly appreciate your cooperation in realizing our plan.