Divine Savior Healthcare Birth Plan

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Divine Savior Healthcare Birth Plan
We encourage you to print this form and write down your wishes and desires for the birth of your baby.
Please discuss these goals with your physician to ensure that your medical needs can be met with this
plan.
How do you feel about inductions if you are past your due
date?_______________________________________________________________________________
____________________________________________________________________________________
Who do you want with you during the process of
labor?_______________________________________________________________________________
____________________________________________________________________________________
Who do you want allowed in the delivery
room?_______________________________________________________________________________
____________________________________________________________________________________
What kind of pain management techniques would you like to consider in early
labor?_______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What would you like your pain managed as labor
progresses?__________________________________________________________________________
____________________________________________________________________________________
How do you feel about medical intervention during labor (not in an emergency situation) such as
“breaking your water,”
Pitocin, episiotomy,
etc.?________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

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