MY BIRTH PLAN
Name: ______________________________________________________________
Expected Due Date: _______________________________________________
FOR LABOR
I would like the following people to be present during labor
and/or birth:
Name: Relation:
_______________________________________ _______________________________
_______________________________________ _______________________________
_______________________________________ _______________________________
_______________________________________ _______________________________
_______________________________________ _______________________________
I prefer the atmosphere to be:
Quiet and as few interruptions as possible
Light dimmed
Few vaginal exams as possible
Limited staff (No students, interns, residents etc.)
To wear my own clothes
I would like a mirror to view my birth
I would like to touch my baby's head as it crowns
To eat and drink as approved by my doctor
To stay hydrated with: _____________________________________________
Photographed or filmed by: ________________________________________
Other requests: ____________________________________________________
_____________________________________________________________________
PAIN MANAGEMENT
Pain relief method(s) I prefer:
Do not offer pain medication unless I request it
I’d like to use alternative medicine like breathing, massage etc.
I'd like to be advised by my doctor/midwife
Entonax Pethidine Birthing Pool TENS Epidural
Other: ______________________________________________________________
DURING DELIVERY
Delivery planned as: Vaginal C-section VBAC Water Birth
Labor/delivery position(s) I prefer if possible:
Standing Squatting Kneeling Sitting
In bed Side-lying Birth Stool Birth ball
Other: ______________________________________________________________
I prefer the following props to have available for my labor:
Birth ball Squat bar Birth stool Other______________________
Fetal monitoring: Intermittent Continuous Other _____________
Episiotomy: Yes Only if it is medically necessary
If my baby needs to be separated due to medical care, I would
like _________________________________________ to accompany him/her.
Doctor/Midwife & Contact #: ______________________________________
Pediatrician & Contact #: __________________________________________
IMMEDIATELY AFTER DELIVERY
Cord clamping: Delayed for ____ minutes Cord stops pulsating
Umbilical cord to be cut by: _________________________________________
Sex of my baby to be announced by: _______________________________
POSTPARTUM / NEWBORN CARE
I would prefer my baby:
to have skin-to-skin contact before bathing and measuring
to be wiped clean before given to me
I would prefer to deliver the placenta:
Naturally Managed with an injection
I would like cord blood handled as follows:
Collected, as pre-arranged by a member of staff
Collected, as pre-arranged by a specialist
Not collected
Medications for my baby:
Erythromycin eye ointment
Hepatitis B vaccine
Vitamin K
Please ask me first before any medication is given to my baby
I plan to feed my baby by:
Breast Pumped breast milk Formula
If my baby is a boy:
I want my baby to be circumcised
I do not want my baby to be circumcised
IMPORTANT HEALTH INFORMATION
Group B Strep: Not tested Positive Negative
Gestational Diabetes: Not tested Positive Negative
Rhesus (RhD) Negative Blood: Yes No
Other Pregnancy Health Condition: _________________________________
________________________________________________________________________
Allergies: _____________________________________________________________
Disabilities/ impairments that could affect the birth process:
________________________________________________________________________
Religious considerations: ____________________________________________
________________________________________________________________________
Other Notes: _________________________________________________________
________________________________________________________________________
© COPYRIGHT 2021 TULAMAMA.COM
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□ □ □ □ □
□
□ □ □ □
□ □ □ □
□ □ □ □
□
□ □ □ □
□ □ □
□ □
□ □
□
□
□ □
□
□
□
□
□
□
□
□ □ □
□
□
□ □ □
□ □ □
□ □
