Birth Plan Worksheet printable pdf download

Birth Plan Worksheet

NAME: ______________________________________________________________________

ATTENDANTS

I'd like the following people to be present during labor and/or birth:

Partner: ___________________________________________________________

Friend/s: __________________________________________________________

Relative/s: _________________________________________________________

Doula: ____________________________________________________________

Children: __________________________________________________________

AMENITIES

I'd like to:

bring music

dim the lights

wear my own clothes during labor and delivery

take pictures and/or video during labor and delivery

HOSPITAL ADMISSION & PROCEDURES

I'd like the option of returning home if I'm not in active labor.

Once I'm admitted, I'd like:

my partner to be allowed to stay with me at all times

only my practitioner, nurse, and guests to be present (i.e., no residents,

medical students, or other hospital personnel)

to wear my contact lenses, as long as I don't need a c-section

to eat if I wish to

to try to stay hydrated by drinking clear fluids instead of having an IV

to have a heparin or saline lock

to walk and move around as I choose

OTHER INTERVENTIONS

As long as the baby and I are doing fine, I'd like to:

have intermittent rather than continuous electronic fetal monitoring

be allowed to progress free of stringent time limits and have my labor

augmented only if necessary

Birth Plan Worksheet