BIRTH PLAN

I. Personal Information

Name	[Your Name]
Partner's Name	[Partner's Name]
Due Date	[Due Date]
Healthcare Provider	[Healthcare Provider]
Hospital/Location	[Hospital/Location]

II. Labor Preferences

Environment

I would like the following to be part of my labor environment:

• Lighting: [Dimmed/Bright/No Preference]

• Music: [Yes/No]

• Additional Support: [Doula/Family/Friends]

Pain Relief

Preferred pain relief methods:

• Medicated: [Epidural/Nitrous Oxide/Other]

• Non-Medicated: [Breathing Techniques/Aromatherapy/Water Birth]

Monitoring

I prefer the following for fetal monitoring:

• [Continuous/Intermittent/No Preference]

III. Delivery Preferences

Pushing

Preferred pushing positions:

• [Squatting/Leaning/Side-Lying/Other]

C-Section

If a C-section becomes necessary, my preferences are:

• Anesthesia: [Spinal/Epidural/General]

• Skin-to-Skin Contact: [Immediately/After Cleaning/No Preference]

Other Interventions

My thoughts on interventions such as episiotomy or forceps:

• [Avoid if possible/Open to discussion/No Preference]

IV. Post-Birth Preferences

Baby Care

Preferences for immediate baby care:

• Breastfeeding: [Immediately/Delayed/Not Breastfeeding]

• Cord Clamping: [Delayed/Immediate/No Preference]

Rooming

Preferences for rooming-in with the baby:

• [24-hour rooming-in/Baby to nursery at night/Other]

Additional Instructions

[Other preferences or requests.]