HTML Preview Baby Birth Plan page number 1.
My Name: Partner’s Name:
OB/Midwife’s Name: Doula/Birthing Coach’s Name:
My Baby-to-Be’s Name: Expected Due Date:
(OPTIONAL)
My Birth Plan
Every birth is different. What can you plan for? More
than you think. Print and fill out this birth plan to prepare
yourself (as much as possible) for delivery. Discuss these
preferences with your OB or midwife so you can decide
which options are best for you and your baby.
Labor Preparation / Preferences:
I have completed the following:
Consent forms (if applicable) Insurance forms Cord blood materials and instructions Other: ________________________
Please note that I:
Have group B strep
Am Rh incompatible with baby
Am positive for herpes
Have gestational diabetes
Other:
None of the above
My preferred delivery method is:
Vaginal
Have had a prior C-section
Have had prior surgery on my uterus
C-section (if checked, move to page 2)
Help for managing labor discomfort:
Natural techniques (such as a bath or shower, breathing
techniques, hypnobirthing techniques or massage)
Regional analgesia (an epidural and/or spinal block)
Please don’t offer me pain medicine. I’ll request it if I need it
Other:
If I have a vaginal birth, I want:
To view the birth using a mirror
To touch my baby’s head as it crowns
For the hospital staff to help me with pushing techniques
To be able to feel the urge before starting to push
Delivery room environment preferences:
Dim lighting
Birthing ball
Music
Minimal sound
Blankets and/or photos from home
Aromatherapy scents that I will provide
Photos taken by:
Other:
I want these people in the delivery room:
Partner:
Parents:
Doula:
Friend:
Other family member:
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