Birth Plan Worksheet


Birth Plan Worksheet
NAME: ______________________________________________________________________
I'd like the following people to be present during labor and/or birth:
Partner: ___________________________________________________________
Friend/s: __________________________________________________________
Relative/s: _________________________________________________________
Doula: ____________________________________________________________
Children: __________________________________________________________
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
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
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


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