Print Me! - Birth Plan Template
by Your Baby ClubName: __________________________ | 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
