 Birth Plan
PARTICIPANT
 Doula
 VBAC
Placenta
Epidural
 H2O
Provider
Birth Preferences:
EDD
Doctor
edd
Name_________________________________________________________DOB_
_________________age_______Provider__________________
EDD_______________________ G________P________ Blood Type__________
GBS________________ Rubella___________________
Allergies___________________________________________________________
_______________________________________________________________
Ht_____________ Pre wt________________
Vaccinations_________________________________________________________
_______________
FOB______________________________________________________________
________________________________________________  M  S
 WATER BIRTH STUDY
Planned C/S
BTL
 Save
Name
CurrentPregnancy:___________________________________________________
_____________________________________________________
__________________________________________________________________
__________________________________________________________________
____
OB
Hx:_______________________________________________________________
_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
____
Other Medical Hx:
__________________________________________________________________
______________________________________
__________________________________________________________________
__________________________________________________________________
____
Social Hx:
__________________________________________________________________
_____________________________________________________
__________________________________________________________________
__________________________________________________________________
____  UDS needed_____________________
 DHS High Risk

COSR & HIPPA signed
Outpt Visits:
__________________________________________________________________
_______________________________________________
__________________________________________________________________
__________________________________________________________________
___
L&D
________________________________________________________
________________________________________________
_________________________________________________________________
_________________________________________________________________
_
Birth
Baby
Name
Date/Time/Type___________________________/__________________
________________________________________________________
___/______________________________
_____Apgars _______/_____/______
Lacerations:____________________________________EBL:_____
Birth
________________________  Birth log
wt:________________________________________________ht:___
_______  Breast  Bottle
Dailys:
hd:____________
 Cord Blood
_____________________
Hypoglycemia Protocol
 NBS  CCHD  TC Bili___________  HT
needed____________________
 UDS