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Create Your Birth Plan
Thank you for choosing Jamestown Regional Medical Center. Your birth plan is a tool that can be helpful for organizing and sharing your preferences during and after childbirth.
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Name
*
First
Last
Physician
*
Baby's Physician
*
Phone
*
Email
*
Expected Due Date
*
Classes You Have Taken
None
Prenatal
Breastfeeding
Happiest Baby on the Block
Select all that apply
Labor Support Person
*
First
Last
Relation to You
*
Cesarean Support Person (if different than Labor)
First
Last
In the case of a non-emergent cesarean section only one support person is allowed.
Allowed During Labor
*
NONE
HUSBAND/PARTNER
CHILDREN
FAMILY
FRIENDS
OTHER
Allowed, if Other
*
Pain Relief Methods You Prefer
*
No Medications
Breathing Techniques
Relaxation
Massage
Walking/Standing/Swaying
Birthing Ball
Water (shower/tub)
Rocking Chair
IV Pain Medication
Intrathecal
Epidural
Other
Select all that apply
Please Explain Other Pain Relief
*
Preferences During Labor
*
Soft lights
Music (must provide own equipment)
Select all that apply. Add other preferences in the comments.
Other Labor Preferences
Any special cultural/spiritual traditions you wish to observe?
Baby
*
GIRL
BOY
UNSURE
For a boy, will you have him circumcised?
*
YES
NO
Feeding Plan
*
Breastfeeding
Breastfeeding-supplement with bottle
Bottle Feeding
Unsure
Select all that appply
Would you like a pacifier for your baby?
*
YES
NO
Visitors & Phone Calls
*
UNLIMITED
LIMITED
NONE
Other Comments
SUBMIT BIRTH PLAN
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