Birth Plan Template printable pdf download

Birth Plan

We encourage you to write down your wishes and desires for the birth and to discuss these with your

physician. Use additional sheets, if necessary.

Your support people:

_____________________________________________________________________________________

Your preferences about pain control:

_____________________________________________________________________________________

Medical interventions during labour:

_____________________________________________________________________________________

Second stage and delivery:

_____________________________________________________________________________________

Most important issues:

_____________________________________________________________________________________

Concerns or fears:

_____________________________________________________________________________________

Infant feeding:

_____________________________________________________________________________________

Newborn procedures:

_____________________________________________________________________________________

The Birth Plan has been reviewed and discussed with me.

Patient’s signature: ______________________________________

Health care provider’s signature: ___________________________

Birth Plan Template