Birth plan template

This birth plan template should be used to convey your preferences to you healthcare providers.   You should include some flexibility should circumstances change to ensure that you are provided with the best care possible.


Your name:         ____________________________________________

E-mail Address:  ____________________________________________

Partner's name: ____________________________________________   

Due date:          ____________________________________________

Name of obstetrician / midwife:  ________________________________   

Other birth-support (doula, other family): ________________________ 

_________________________________________________________


Where do you want to give birth?
Hospital      (name of hospital) _______________________________
Birth Centre (name of birth centre) ___________________________
At home     
Not sure yet

Labour & Birth
 
Environment
tick as many as you like
Dim Lights
Quiet Music
Aromatherapy Oils 
Wear my own clothes     
OK to have training medical staff observe labour & birth
Other          ____________________________________________  

Mobility during Labour
I would like to keep active during labour if possible (walking, fitball, etc.)     
Mobility is not important to me     

Relaxation and Comfort during Labour
tick as many as you like
Massage    
Bath      
Shower
Fit Ball
Bean Bag
Hot towels       
Acupressure     
Hypnotherapy     
Other          ____________________________________________   

Do you want to use any special facilities?
Birthing pool
Other          ____________________________________________

Position(s) for Labour & Birth
tick as many as you like - underline preferred birth position
Walking
Standing
Squatting
Sitting     
Kneeling     
Lying down
Birth Stool
Other          ____________________________________________    

Foetal Monitoring
Continuous monitoring (will mean limited mobility)
Intermittent monitoring
No monitoring - except in emergency situations     

Vaginal / Cervix Examinations
I would like minimal examinations
I am happy for examinations as deemed necessary by medical staff
No monitoring - except in emergency situations  

Pain Relief
Do not offer; I will ask if I want pain relief    
Offer if I appear uncomfortable     
Offer as soon as possible     

Medical Pain Relief Options
number any acceptable options in order of preference
I would like to try to manage without medical pain relief options
Gas / Air
Pethidine     
Epidural    
Other          ____________________________________________   
   
Rupturing of the amniotic sac     
I prefer my amniotic sac be allowed to rupture on its own

Episiotomy
I do not want an episiotomy unless there is an emergency situation     
I would like an episiotomy to reduce the risk of tearing     
   
Delivery
I would like to touch baby's head when it crowns     
I would like a mirror available to view pushing/crowning/birth     

Immediately following delivery
tick as many as you wish
I want baby placed on my chest immediately after birth
Please delay cord clamping and cutting until pulsating ceases
I would like my birth-partner to cut the cord
I would like to cut the cord     
Birth-partner does not want to cut cord     
I would like to hold the baby while the placenta is delivered
I do not want an injection to assist with placenta delivery     
I would like the baby to be examined in my presence     
If the baby cannot be examined in my presence, I would like my birth-partner to remain with the baby at all times     
I want to donate cord blood to the public cord blood bank (if service is available)
I want to bank cord blood privately    

Assisted Delivery
If additional medical assistance is required for the birth, I would prefer:
assisted delivery - forceps
assisted delivery - ventouse
caesarean section

Caesarean
In the event that a cesarean section is deemed necessary, I would like the following:
Birth-partner present     
Other support present ______________________________________     
Photos / video     
Screen lowered at delivery     
I would like the procedure described as it is happening     

Anything else _________________________________________________     



Baby Care

Feeding Baby
I wish to breastfeed exclusively     
I wish to breastfeed, but formula supplementation is acceptable     
I wish to formula feed     
I do not want baby to be given a pacifier     
I would like to meet with a lactation consultant  

Vitamin K
I would like my baby to have the single injection of Vitamin K     
I would like my baby to have oral Vitamin K  
I do not want my baby to have Vitamin K    

Hepatitis B
I would like my baby to be vaccinated with Hepatitis B vaccine before discharge

Any Special Dietary Requirements for the new Mum

___________________________________________________________

___________________________________________________________


Any other special needs for new Mum and/or birth-partner (language, religion, disability, etc)

___________________________________________________________

___________________________________________________________


Length of stay in hospital
I would like to have as short a stay as possible in hospital
I would like to stay in hospital for 1-2 days after the birth
I would like to stay in hospital for more than 2 days after the birth


In the event that baby requires special care due to trauma or illness
I would like to breastfeed/pump breast milk     
Birth-partner will accompany baby if transferred to another hospital     
I would like to be transferred to baby's hospital   


Useful Resources
more tips on writing your birth plan
hospital & labour bag packing checklist
'essential nursery items' checklist




Your Signature _________________________________ Date _________


Healthcare Provider's Name _____________________________________

Healthcare Provider's Signature ____________________ Date _________