Print Me! - Birth Plan Template

by Your Baby Club

Name: __________________________

Due date: ___________________

Where I want to give birth:

☐ Hospital

☐ Birthing unit

☐ At Home

☐ Undecided

Name or address of birth location: ________________________________

Birthing Partner

☐ I want someone with me

☐ I want more than one person with me

☐ I’m not sure

Name of birthing partner(s): _____________________________________

Relationship to you: ____________________________________________

Forceps/Ventouse Deliveries

Cesarean Delivery

☐ I've had the procedure explained to me and understand it may be necessary during my labour

☐ I've had the procedure explained to me and understand it may be necessary during my labour

☐ I’d like this procedure explained to me in more depth

☐ I'd like an elective c-section

☐ I’d like my partner or companion with me

☐ I’d like my partner or companion with me

Activity During Labour

☐ I would like to move around

☐ I wouldn’t like to move around

☐ I don’t mind

☐ I’m not sure yet.

Positions (tick all that apply)

☐ In bed with pillows

☐ Standing

☐ Sitting

☐ Kneeling

☐ On all fours

☐ Laying on one side

☐ Not sure yet

☐ Other (please specify) _________________________________________

Monitoring

☐ I have discussed with my midwife how I would like my baby’s heart to be monitored

Chosen method: _______________________________________________

Midwives/Nurses/Doctors in Training

☐ I don’t want a trainee present

☐ I don’t mind

Pain Relief Options

☐ Breathing & relaxation

☐ Hypnobirthing

☐ Gas & air

(entonox)

☐ Massage

☐ Acupuncture

☐ TENS machine

☐ Pethidine

☐ Epidural

☐ None

☐ Other (please specify) _________________________________________

Episiotomy

☐ I understand it may be necessary

☐ I’d rather not have one

Birthing Equipment

☐ Beanbag

☐ Birthing ball

☐ Mats

☐ Stool

☐ TENS machine

☐ Pool

☐ None of the above

☐ I’m not sure if I want to use these yet

☐ I will bring my own

☐ To be provided if available

Special Facilities

☐ LDRP room (labour, delivery, recovery, postnatal rooms)

☐ Birthing pool (if available)

☐ I’m not sure yet

☐ Other (Please specify) ________________________________________

Skin-to-Skin Contact

☐ I’d like my baby placed straight on me

☐ I’d like my partner to hold them first

☐ I’d like my baby cleaned before given to me

☐ I don’t mind

☐ I haven’t decided yet

Any specific requests: __________________________________________

Other Considerations

☐ Myself or my partner would like to cut the cord

☐ I’d like the clamping of the cord delayed

☐ I’d like a lotus delivery

☐ I don’t mind

Placental Delivery

☐ I would like an assisted delivery

☐ Let it deliver naturally

☐ I don’t mind

☐ I would like to keep the placenta

☐ Please dispose of it

☐ I’d like to donate it

If you’d like to keep the placenta, have you arranged for collection?

☐ Yes ☐ No

Feeding my Baby

☐ Breastfeeding

☐ Bottle feeding

☐ Mixture

☐ I’m not sure

Vitamin K

☐ I consent to Vitamin K being given to my baby

☐ I do not consent

Special Requirements

☐ I will need an interpreter as English is not my primary language

☐ I will need a sign language interpreter

☐ I have special dietary requirements

☐ I and/or my partner have special needs

☐ I would like certain religious/cultural customs observed (give details below)

Additional Comments


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Your Baby Club

Your Baby Club HQ
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