Birth Plan Sample/Considerations

UMMPOWERED BIRTH PREFERENCES

"Informed. Empowered. Flexible."

Mother's Name: __________________________

Due Date: _______________________________

Provider: ________________________________

Birth Location: ___________________________

Support Team Present:☐ Spouse/Partner ☐ Doula ☐ Family Member ☐ Photographer ☐ Other: __________________

Primary Person for Questions:☐ Me ☐ My Partner ☐ Other: __________________

MY BIRTH VISION

My hopes for this birth experience are: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LABOR PREFERENCES

Environment

☐ Dim lighting

☐ Quiet environment

☐ Qur'an recitation

☐ Dhikr/Islamic reminders

☐ Music

☐ Minimal interruptions

☐ Aromatherapy (if permitted)

☐ Freedom to move

☐ Birth ball

☐ Peanut ball

☐ Shower

☐ Tub/water therapy

Other:

Comfort Measures

I would like to try:

☐ Position changes

☐ Walking

☐ Massage

☐ Counterpressure

☐ Hip squeezes

☐ Heat

☐ Cold therapy

☐ Rebozo techniques

☐ Breathing exercises

☐ Visualization

☐ Labor support coaching

Pain Relief Preferences

☐ Unmedicated if possible

☐ Open to nitrous oxide

☐ Open to IV pain medication

☐ Open to epidural

☐ Please do not offer pain medication unless I ask

Notes: ____________________________________________________________________________________________________________________________________________________________________

MEDICAL INTERVENTIONS

Please discuss and obtain consent before:

☐ Artificial rupture of membranes

☐ Pitocin augmentation

☐ Continuous monitoring

☐ Internal monitoring

☐ Vacuum assistance

☐ Forceps assistance

☐ Episiotomy

☐ Cesarean birth

Additional preferences: ____________________________________________________________________________________________________________________________________________________________________

BIRTH PREFERENCES

Pushing

Preferred positions:

☐ Upright

☐ Side-lying

☐ Hands and knees

☐ Squatting

☐ Birth stool

☐ Position of comfort

During Birth

☐ Mirror available

☐ Touch baby's head while crowning

☐ Help catch my baby

☐ Partner catches baby

☐ Provider catches baby

☐ Learn baby's sex at birth

Cord & Placenta

☐ Delayed cord clamping

☐ Partner cuts cord

☐ Doula photographs cord cutting

☐ Cord blood banking

☐ Keep placenta

☐ Placenta encapsulation planned

IF CESAREAN BECOMES NECESSARY

If a cesarean becomes medically necessary, I would like:

☐ Explanation before procedures

☐ Support person present

☐ Doula present if permitted

☐ Clear drape if available

☐ Immediate skin-to-skin if possible

☐ Breastfeeding in recovery

☐ Partner accompanies baby if separation occurs

Notes: ___________________________________________________________

GOLDEN HOUR

After birth, if mother and baby are stable:

☐ Immediate skin-to-skin

☐ Delay routine procedures

☐ Uninterrupted bonding

☐ Begin breastfeeding within first hour

☐ Partner participates in skin-to-skin

☐ Minimal visitors

NEWBORN CARE

Feeding

☐ Exclusive breastfeeding

☐ Breastfeeding with expressed milk

☐ Formula if medically necessary

☐ Undecided

Procedures

Please discuss before:

☐ Vitamin K

☐ Eye ointment

☐ Hepatitis B vaccine

☐ Blood sugar checks

☐ Nursery separation

☐ Supplementation

Baby Care

☐ Rooming-in

☐ Delay first bath

☐ Partner present for procedures

☐ Circumcision planned

☐ Circumcision not planned

ISLAMIC CONSIDERATIONS (OPTIONAL)

☐ Adhan in baby's right ear

☐ Iqamah in baby's left ear

☐ Family member will perform Adhan

Name: __________________

☐ Modesty considerations requested

☐ Female providers preferred when available

☐ Halal dietary considerations

☐ Du'a and Qur'an recitation encouraged

Additional notes: _______________________________________________

IMPORTANT TO ME

Please know that my highest priorities are:

☐ Healthy mother

☐ Healthy baby

☐ Informed consent

☐ Shared decision-making

☐ Low-intervention birth

☐ Physiological birth

☐ Breastfeeding support

☐ Immediate bonding

☐ Respectful communication

Other: _________________________________________________________________