My Birth Plan Page 2

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My Birth Plan
Patient Name: _______________________________________________________________________
Support Person: _____________________________________________________________________
My Labor:
My Birth Plan outlines my preferences for my baby’s birth and care
during my hospital stay. I understand flexibility is required depending
My feelings and wishes for labor: _______________________________________________________
on the course of my labor and the well-being of my baby.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
My Information:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name: _________________________________________ My Date of Birth: ____________________
____________________________________________________________________________________
Physician/Certified Nurse Midwife: ____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
My Baby’s Physician: ________________________________________________________________
Due Date: __________________________________________________________________________
o Low lighting
o Freedom to move/position according to how I feel
o Quiet room
o Birthing chair
o Listen to music
o Eat and drink according to how I feel
o Aromatherapy
o Drinking clear fluids and eating ice chips
o Shower/whirlpool
o Wearing my own clothes
o Breathing and relaxation techniques
o Bring my own pillows
o Massage
o Pushing in positions of my choosing
o Birthing balls
o Pushing with the use of the squatting/birthing bar
o Visualization/Focal point
o Pushing while on hands and knees
o Ice Packs/Warm packs
o Pushing while lying on my side
o Walking
o I am not concerned with positioning

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