my birth plan

My birth plan

Your first name: Your surname: Name I like to be called i.e Catherine = Cathy:
Your birthing companion’s name(s):

Your due date:

Is there a particular midwife you would like to be there if she / he is available?
Yes No

If yes, midwife’s name: Midwife’s phone number:

Would you like your birthing partner(s) to be with you throughout labour?
Yes Not necessarily

What position would you like to be in for the birth?
Standing Squatting Kneeling Sitting In bed Side lying Birth stool Birth ball Water birth Other:
How would you like the atmosphere in the room?
Quiet Low lighting Music/radio playing in the background
Other: (please specify)
If possible, would you prefer to be cared for and delivered by a woman?
Yes No I don’t mind

Student midwives or medical students can provide invaluable support to parents during labour. If possible, are you happy to have them present at the birth?
Yes No I don’t mind

Pain relief

Would you like any pain relief?
Yes No Would like to be advised by midwife
As little as possible I’d like to decide at the time

What pain relief would you like?
Entonox (gas & air) Pethidine I don’t mind TENS Epidural Birthing pool Alternative therapy i.e. massage, aromatherapy:

Other:

www.hipp.co.uk Assisted delivery

If an assisted delivery is necessary, which method would you prefer?
Ventouse Forceps Will allow midwife / obstetrician to make choice

How do you feel about an episiotomy if required?
Only if necessary I’d like to avoid having one

After the birth

Would you like your partner to cut the umbilical cord?
Yes No

Would you like your baby put straight onto your tummy or cleaned up first?
Onto my tummy Cleaned up first

Would you like to be told the sex of your baby?
Yes No, I want to make the discovery myself
I already know the sex of my baby I would like my partner to tell me

How would you like the placenta to be delivered?