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My Birth Plan You can complete the highlighted

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My Birth Plan
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text that is visible on the form is printed; scrolled text will not print. Any text you enter into these fields will be
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Name:
Doctor's or midwife's name:
Partner's name:
Today's date:
This birth plan is a guide for my labor 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 center:
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 labor and birth:
Partner: (Names)
Friend(s):
Family:
Doula:
1
During Labor
I'd like to be able to go back home if I'm not in active labor.
After 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.
2
If I decide to use medicine for pain, I prefer:
Epidural anesthesia.
Local anesthesia.
Pudendal or paracervical block.
A narcotic.
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.
Breast-feed 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.
Breast-feed only.
Bottle-feed with formula only.
3
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.
© 1995-2016 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks
of Healthwise, Incorporated.
Thi
s information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this
information.
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Completed 27 June 2022

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