Birth Plan Template

A comprehensive BIRTH PLAN is a record of what you would like to happen during your labour and after the birth of your baby/babies. It is an excellent way of preparing yourself for delivery and understanding the options that may be available to you, both during and after the birth. In the preparation of your birth plan, you will no doubt make important decisions concerning your preferences of your labour and birth. Discuss these with your partner, family, friends and practitioner to ensure you are fully informed about all of your options.

It is always extremely important to bear in mind that pregnancy, especially one with any potential complications, such as a multiple birth, does not always go to plan and that you may need to be flexible on your preferences in the event of unforeseen circumstances. In addition to this, what is advisable to one mother and what available in one hospital or unit depends entirely on the individual situation. Your medical history will need to be taken into consideration as well as your wishes. There is no single correct way to give birth.

Please feel free to use the following Birthing Plan as a rough guide of your own Pregnancy Plan:

I welcome any feedback or comments (see bottom). Thanks

_______________________________________________________________

My Birthing Plan

General Information

Expected due date:____________________________________________

I would like ______________________________ to be present at the birth.

I am giving birth in _____________________________________________.

I need a translator/sign language interpreter/special diet_______________

I have the following special needs __________________________________

My religion requires me to__________________________ ______________

Labour

I would like my partner to remain with me at all times, if possible. Yes/No

I would prefer to be cared for by women only. Yes/No

I would like to be offered pain relief. Yes/No

The pain relief I am interested in is: (circle)

• TENS machine
• Gas and Air
• Epidural
• Pethidine
• Meptid
• Other ________________________________________

I am interested in alternative therapies: (circle)

• Aromatherapy
• Reflexology
• Massage
• Other___________________________________________________

If possible, I would like the following to be available to me during labour: (circle)

• Bean bags
• Birth ball
• Birth stool
• Mats
• A fan
  
• Other_______________________________________________

I would like to use a birth pool Yes/No

The ideal position for me to give birth is ______________________________

I would like my labour and/or birth to be filmed or photographed by _________

I would prefer students were not present. Yes/No

Delivery

If it is necessary for me to be induced, I prefer the following method: (circle)

• Artificial rupture of membranes
• Syntocinon
• Prostglandin

If assisted delivery is necessary, I would prefer: (circle)

• Forceps
• Ventouse

If there is a risk of tearing, I would prefer: (circle)

• To tear naturally
• To have an episiotomy

Monitoring

I would prefer to be monitored via: (circle)

• Intermittent hand-held foetal monitor
• Continuous External Monitor

Cesarean Section

If I need to have a Cesarean section, I would prefer: (circle)

• My partner to remain with me
• To see my baby as soon as possible
• For me (or my partner if I cannot) to hold my baby as soon as possible

Post-Delivery

If possible, I would like ________________________to cut the umbilical cord.

I would like for my baby: (circle)

• To be placed on my tummy
• To be given to my partner
• To be cleaned up straight away
• To be breastfed as soon as possible

Placenta (the third stage of delivery)

I would prefer: (circle)

• Unassisted delivery
• An injection to speed it up

My stay in hospital

I would prefer:

• Six hour discharge
• 24 hour discharge
• A longer stay

I would like a private room, if possible. Yes/No

Signature

I understand that not all of my requests may be possible to be followed in the event of unforeseen circumstances.

Signed ________________________________ Date ___________

_______________________________________________________________

Once you have completed your birth plan, it is advisable to carry it with you in the later stages of your pregnancy along with your pregnancy notes.

I hope this birth plan template has been of use to you. If so, please recommend it to your friends and family, or comment below.