About Baby Birth Plan (Page 2 of 4) in pdf

St. Luke’s About Baby Birth Plan is a way of communicating your labor and birth preferences

with your doctor or midwife and nurses in the hospital. Simply put, this is a listing of the choices

and preferences you and your partner have about labor, birth and your hospital stay.

Bring this completed form back, and we will review it with you to ensure that we understand your

wishes at any time during your pregnancy (before 30 weeks preferred).

Our staff will do its best to honor your plan. Your safety and your baby’s safety are the top priority.

It’s best to be ﬂexible as you draft your birth plan—look at it as a list of preferences that may need

to be adjusted as labor progresses.

My name:

Doctor or midwife:

Doula:

Support person(s):

Date completed:

___________________________

Revised on:

___________________________

I would like these people present in my private room during labor:

_________________________________________________________________________________

I would like these people present in my private room during delivery:

_________________________________________________________________________________

I want my delivery team to know: (check all that apply)

[ ] Privacy is very important to me

[ ] I want the room quiet and relaxing

[ ] I enjoy humor and a fun environment

[ ] I want everything explained—always

[ ] I don’t have a strong preference and want to go with the ﬂow

[ ] Additional:

_________________________________________________________________________________

About Baby Birth Plan Page 2