BIRTH PLAN

Personal Information

Name: [Your Name]

Birth Partner's Name: [Partner's Name]

Due Date: [Due Date]

Doctor/Midwife: [Doctor/Midwife Name]

Hospital/Birth Center: [Hospital/Birth Center Name]

Contact Number: [Your Company Number]

Labor Preferences

Environment

• Preferred Room Setup: [Room Setup Preferences]

• Lighting: [Lighting Preferences]

• Music/Noise Level: [Music/Noise Level Preferences]

Pain Management

• Natural (Unmedicated)

• Epidural

• Other Medications: [Other Medications]

• Alternative Methods: [Alternative Methods e.g]

Labor Positions

• Standing

• Sitting

• Lying Down

• Walking

• Other: [Other Positions]

Delivery Preferences

Delivery Method

• Vaginal Birth

• Caesarean Section

• Additional Preferences: [Additional Preferences]

Episiotomy

[Episiotomy Preference]

Umbilical Cord

• Cut by: [Partner's Name/Doctor]

• Delayed Clamping: [Preference]

Immediate Post-Birth

• Skin-to-Skin Contact: [Preference]

• Breastfeeding Initiation: [Time Preference]

Postpartum Preferences

Mother

• Rooming-in with Baby: [Preference]

• Lactation Support: [Preference]

• Other post-birth care: [Other Preferences]

Baby

Newborn Procedures	Accept/Decline
Eye Treatment	[Accept/Decline]
Vitamin K Shot	[Accept/Decline]
Hepatitis B Vaccination	[Accept/Decline]

Additional Notes

[Any additional notes]