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my birth plan

overview

name: ___________________________________. partner's name: _____________________________.

doctor or midwife's name: __________________________. today's date: _____________________.

this birth plan is a guide for my labour and delivery. since childbirth does not always go as planned, some of this birth plan may change.

place and people

i would like to deliver my baby:

__ in a hospital: _______________________________________(name, phone number).

__ in a birthing centre: _______________________________________(name, phone number).

__ at home.

i would like my baby to be delivered by:

__ my family doctor: _________________________________________(name).

__ my obstetrician: ________________________________________________.

__ my midwife: ____________________________________________________.

__ my perinatologist: _______________________________________________.

i'd like these people to be with me during labour and birth:

__ partner: ________________________________________________(name).

__ friend(s): _____________________________________________________.

__ family: _______________________________________________________.

__ doula: ________________________________________________________.

during labour

__ i'd like to be able to go back home if i'm not in active labour.

once i've been admitted, i'd prefer:

__ to eat if i wish to.

__ to drink clear fluids instead of having an iv.

__ to walk and move around if i can.

i'd like to try:

__ a birthing chair.

__ a birthing stool.

__ a squatting bar.

__ a birthing tub or pool.

when the time comes to push, i'd like to:

__ be coached on when to push and for how long.

__ push when i feel i need to (instinctively).

i'd prefer to use the following position(s):

__ half lying down (semi-reclining).

__ squatting.

__ lying on my side.

__ whatever feels best at the time.

i'd like to use the following for pain management:

__ acupressure

__ breathing techniques

__ self-hypnosis

__ massage

__ medicine

__ other: _______________________________________________________________.

__ please do not offer me pain medicine. i'll ask for it if i need it.

if i decide to use medicine for pain, i prefer:

__ epidural anesthesia.

__ local anesthesia.

__ pudendal or paracervical block.

__ an opioid.

birth

i would like to:

__ take all possible steps to avoid an episiotomy.

__ view the birth using a mirror.

after the birth, i'd like to:

__ hold my baby right away, before any procedures that are not urgent.

__ breastfeed as soon as possible.

__ have my partner cut the umbilical cord.

c-section

if i have a c-section, i:

__ would like to see my baby coming out.

__ would like my partner present during the operation.

after the birth

after delivering the baby, i'd like to:

__ have my partner be with the baby whenever i can't be.

__ stay in a private room.

__ have my partner stay with me in my room.

__ breastfeed only.

__ bottle-feed with formula only.

please offer my baby:

__ formula.

__ pacifier.

__ nothing without my permission.

i'd like my baby to be:

__ in my room 24 hours a day.

__ in my room only when i'm awake.

__ with me only for feeding.

__ with me based on how well i feel at the time.

if i have a baby boy:

__ i'd like him circumcised at the hospital.

__ i'll have him circumcised later.

__ i will not have him circumcised.

__ i'll decide about circumcision later.

related information

credits

current as of: july 10, 2023

author: healthwise staff
clinical review board
all healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

this information does not replace the advice of a doctor. healthwise, incorporated, disclaims any warranty or liability for your use of this information. your use of this information means that you agree to the terms of use. learn how we develop our content.

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