Birth Plan Form

Lets an expecting mother document her detailed preferences for labor, delivery, and immediate newborn care.

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General information

Your Name

Nombre

Apellido

Expected Due Date

Phone Number

Partner Name

Nombre

Apellido

Baby-to-be's Name

Nombre

Apellido

Midwife

Nombre

Apellido

Pediatrician

Nombre

Apellido

Doula

Nombre

Apellido

You completed

Childbirth Class Hospital Tour Breastfeeding Class Infant CPR Course

Please select the ones applicable to you

High-risk Pregnancy Gestational Diabetes Previous Cesarean Multiple Pregnancy None of the above

Do you take the any prescription medications?

Yes No

Do you take the any medication allergies?

Yes No

Please give details

Section

Preferred method of delivery

Vaginal Cesarean No Preference

You want (If you have a vaginal birth)

Freedom to move during labor Water birth Delayed cord clamping No preference

Please select the one(s) you want in the delivery room

What do you want as a help for managing labor discomfort:

During Labor you prefer

Section

Labor Induction and Interventions

Options to help prepare your cervix(also referred to as cervical ripening)

Membrane Sweep Foley Bulb Medication Natural Methods

In case of interventions such as vacuum, forceps or episiotomy, what you prefer?

Avoid if possible Doctor's discretion Discuss with me first

Options to help with contractions

Hydrotherapy Massage Position Changes Medication

If you need a C-section and it's not an emergency

Partner present Immediate skin-to-skin Clear surgical drape Music in the operating room

Section

You want to hold your baby for the first time:

Immediately After cleaning After the medical check

Procedure for the umbilical cord and placenta:

Delayed clamping Partner cuts the cord Save the placenta No preference

If your baby is a boy:

Circumcision No circumcision Undecided

You prefer followings for your baby:

Vitamin K Eye Ointment Hepatitis B Vaccine None

You prefer to feed your baby with:

Breastfeeding Formula Combination

You prefer to start breastfeeding

Immediately Within the first hour When baby is ready

Section

Select the items you want in your hospital bag (If you go into labor unexpectedly, your hospital may be able to provide you with some essential items.)

Your Notes

Birth Plan Form

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