Birth Plan Template printable pdf download

Birth Plan Template

Birth Plan

Full Name:____________________ Partner’s Name:______________________

Provider: OB-GYN, P.C.

*I would like ______________________________________________________

present in the delivery room with me.

*You should know that I

_____ have group strep B

_____am Rh negative

_____have gestational diabetes

*Having access to a birth ball/peanut/bean bag/squatting bar/bath tub are,

_____ Important to me.

_____ NOT important to me, but if you find they may be helpful, please suggest them to me.

*For Pain relief I would like,

_____to know my options immediately

_____to NOT be offered any pain meds unless I request them

_____to use breathing, positioning, and relaxation techniques

*As baby is being delivered/when baby is delivered, I would like,

_____ to touch baby’s head as it crowns/help catch the baby

_____ to do skin to skin care immediately

_____ to allow the cord to be done pulsating before it is clamped

_____ to donate cord blood to Michigan Blood

_____ to collect cord blood for private banking

_____ to have partner cut the cord

Birth Plan Template