This birth plan is for:

Baby's due date:

 

Whom do you want to have with you as your birth partner during labour?
Partner Friend
Names :
(Restrict to a maximum of two birth partners only)
 
Do you want your birth partner to remain with you if you have stitches or a caesarean?
Yes No
 
Do you want to be as mobile as possible during labour?
Yes No
 
What type of positions would you prefer to be in during labour and delivery?
Upright              Squatting              Walking              Decide at the time
 
What type of environment would you prefer?

 


 
(You could have dim lights, music, cushions, bean bag, birth pool etc. If you are planning to use beanbags, birth pool etc., it is best to check with the hospital if these facilities are available.)
 
What are your feelings about being induced if you go past your due date?
I want to be induced I don't want to be induced
 
How do you feel about foetal monitoring?
Accept it Don't accept it
 
Would you agree to an enema, if required?
Yes No
 
Would you want your pubic hair to be shaved, if required?
Yes No
 
How would you feel about speeding up labour artificially, if required?
I agree I disagree
 
Would you like to make use of breathing and relaxation techniques learnt in your antenatal classes?
Yes No
 
Would you mind if medical students are present during your labour and delivery along with doctors and midwives?
Yes No
 
Would you want to be cared by women professionals only?
Yes No
 
Do you need any interpreters?
Yes No
 
Would you be using any pain relief during labour?
Yes No
 
If using pain relief, what preferences do you have?
Gas & Air            Pethidine            TENS            Epidural            Other
 
What are your feelings about assisted delivery (using forceps or ventouse)?
Agree Disagree
 
Would you prefer an episiotomy as opposed to tearing naturally?
Yes No
 
Would you want to see your baby's head being delivered?
Yes No
 
Would you want your birth partner to cut the umbilical cord?
Yes No
 
Would you like the baby to be delivered straight onto your abdomen or cleaned before being handed over to you?
  Delivered straight on abdomen                              Cleaned first
 
How do you plan to feed your baby (breast or bottle)?
Breast Bottle
 
If breastfeeding, do you want the baby to be put to the breast straightaway?
Yes No
 
How would you like the placenta to be delivered? (Naturally or through the use of syntometrine which speeds up the delivery of the placenta)
Naturally Artificially
 
Do you want your baby to have vitamin K?
Yes No