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.