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Birth Plan Questionairre
Familiarize yourself with each of the following interventions, then please rate your feelings about avoiding the following procedures.
1 - I absolutely desire this procedure/intervention
2 - I would prefer this procedure/intervention
3 - I do not care if I have this procedure/intervention
4 - I would rather avoid procedure/intervention
5 - I absolutely DO NOT want this procedure/intervention
| Enema | 1 | 2 | 3 | 4 | 5 |
| Shave prep | 1 | 2 | 3 | 4 | 5 |
| IV during labor and birth | 1 | 2 | 3 | 4 | 5 |
| Heparin lock instead of IV | 1 | 2 | 3 | 4 | 5 |
| Labor in hospital gown vs. own clothing | 1 | 2 | 3 | 4 | 5 |
| Nothing to drink or eat during labor | 1 | 2 | 3 | 4 | 5 |
| Artificial rupture of membranes | 1 | 2 | 3 | 4 | 5 |
| Labor induction (all methods) | 1 | 2 | 3 | 4 | 5 |
| Labor augmentation (pitocin) | 1 | 2 | 3 | 4 | 5 |
| Pitocin (induction, augmentation, third stage) | 1 | 2 | 3 | 4 | 5 |
| Continuous external fetal monitoring | 1 | 2 | 3 | 4 | 5 |
| Continuous internal fetal monitoring | 1 | 2 | 3 | 4 | 5 |
| Urinary catheter | 1 | 2 | 3 | 4 | 5 |
| Epidural pain relief | 1 | 2 | 3 | 4 | 5 |
| Narcotic pain relief | 1 | 2 | 3 | 4 | 5 |
| Episiotomy | 1 | 2 | 3 | 4 | 5 |
| Cesarean Birth | 1 | 2 | 3 | 4 | 5 |
| Perineal tear (not a procedure) | 1 | 2 | 3 | 4 | 5 |
| "Purple" pushing | 1 | 2 | 3 | 4 | 5 |
| Pushing on your back | 1 | 2 | 3 | 4 | 5 |
| Use of stirrups | 1 | 2 | 3 | 4 | 5 |
Assuming your caregiver said there was a good reason for the following procedures, how much would each upset you?
| Artificial rupture of membranes | not at all | a little | not sure | a lot | extremely |
| Induction | not at all | a little | not sure | a lot | extremely |
| Augmenting labor | not at all | a little | not sure | a lot | extremely |
| Continuous external monitoring | not at all | a little | not sure | a lot | extremely |
| Internal monitoring | not at all | a little | not sure | a lot | extremely |
| Episiotomy | not at all | a little | not sure | a lot | extremely |
| Vacuum extraction | not at all | a little | not sure | a lot | extremely |
| Forceps delivery | not at all | a little | not sure | a lot | extremely |
| Cesarean section | not at all | a little | not sure | a lot | extremely |
Newborn choices-
Using the scale on the previous page, please rate the following newborn procedures/practices.
| Baby going to nursery* | 1 | 2 | 3 | 4 | 5 |
*Separation from mom (warmer, assessment, etc.)
| Breastfeeding as soon as possible (immediately) | 1 | 2 | 3 | 4 | 5 |
| Baby receives artificial nipples | 1 | 2 | 3 | 4 | 5 |
| "Suck Test" (test of sucking reflex on bottle of sugar water) | 1 | 2 | 3 | 4 | 5 |
| Vitamin K Injection | 1 | 2 | 3 | 4 | 5 |
| Antiobiotic eye treatment | 1 | 2 | 3 | 4 | 5 |
| Hepatitis B Vaccine | 1 | 2 | 3 | 4 | 5 |
| Circumcision (If it's a boy) | 1 | 2 | 3 | 4 | 5 |
**Please also consider stating if, when and how you would like your baby's first bath to be given as there are advantages to postponing the first bath.
In making your choices regarding the care of yourself and your baby, please do so carefully. I have tried to provide you with as much information possible here to help you make those choices. There is a wealth of information out there…so if you need more, please find it before you make your final decisions.
Good Luck and Good Birthing!
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Because Birth is Sacred
protectbirth@gmail.com
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