Overview

Name: ___________________________________. Partner's name: _____________________________.

Doctor or midwife'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: _______________________________________(name, phone number).

__ 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: ________________________________________________(name).

__ Friend(s): _____________________________________________________.

__ Family: _______________________________________________________.

__ Doula: ________________________________________________________.

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.

If I decide to use medicine for pain, I prefer:

__ Epidural anesthesia.

__ Local anesthesia.

__ Pudendal or paracervical block.

__ An opioid.

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.

__ Breastfeed 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.

__ Breastfeed only.

__ Bottle-feed with formula only.

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.