Name: ___________________________________. Partner's name: _____________________________.
Doctor or midwife's name: __________________________. Today's date: _____________________.
This birth plan is a guide for my labour 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 centre: _______________________________________(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 labour and birth:
__ Partner: ________________________________________________(name).
__ Friend(s): _____________________________________________________.
__ Family: _______________________________________________________.
__ Doula: ________________________________________________________.
__ I'd like to be able to go back home if I'm not in active labour.
Once 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).
__ Lying on my side.
__ Whatever feels best at the time.
I'd like to use the following for pain management:
__ Breathing techniques
__ 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.
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.
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:
__ 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.
Current as of: May 29, 2019
Author: Healthwise Staff
Medical Review: Kathleen Romito, MD - Family Medicine
Adam Husney, MD - Family Medicine
Kirtly Jones, MD - Obstetrics and Gynecology, Reproductive Endocrinology