Birth Plans

Some ladies go in with a step by step birth plan detailing how they want every moment of their birth to unfold, and others walk in with no intended plan and just go with the flow. No matter where you sit on this spectrum it is always good to know your options to be able to make informed decisions about and situation or procedure that may occur. This birth plan is only a guide. Please read through and make adjustments that suit your birth.

Gently labouring in the tub

Where do I want to give birth?

□ Hospital

□ Birth Centre

□ Home

Who do I want to attend the birth?

□ Partner

□ Children

□ Other Family Members/Friends

□ Friends

□ Doula

□ Birth Photographer

Who do I want my birth environment to look like?

□ Music

□ Low Lighting

□ Aromatherapy

□ Affirmation Cards

□ Own Clothing

□ Hospital Gown

Techniques for pain relief Unmedicated:

□ Massage/Pressure

□ Shower/Bath

□ Rebozo

□ Hot/Cold Packs

□ Hypnobirthing

□ TENS Machine

□ Acupressure

□ Nipple/Genital Stimulation


□ Gas & Air

□ Pethidine

□ Epidural (anaesthesia)

□ Spinal Block (caesarean section only)

What birthing aids would I like to use?

□ Peanut Ball

□ Fit Ball

□ Birthing Stool

□ Beanbag

□ Squatting Bar

□ Birth Pool


□ Prefer to stay in one position

□ Prefer to move about during labour


□ Walking

□ Squatting

□ Kneeling

□ Standing

□ Sitting

□ Lying Down

Foetal Monitoring

□ Continuous Monitoring

□ Intermittent Monitoring

□ Doppler Monitoring

Please be aware that high risk pregnancies, induction and epidural use births are likely to have continuous monitoring for the safety of baby.

Internal Checks/Breaking of Amniotic Sac

□ Happy with examinations deemed necessary by medical staff

□ Minimal Examinations

□ No Examinations unless in an emergency

□ Midwife/Doctor can break my amniotic sac

□ I want my amniotic sac to break naturally


□ I want to feel my babies head

□ I want to have a mirror to see the pushing and crowning stages

□ I want to catch my baby

□ I want my partner/support person to catch my baby


□ I agree to an episiotomy if necessary

□ I disagree to an episiotomy

□ I agree to a forceps delivery if necessary

□ I disagree to a forceps delivery

□ I agree to a vacuum delivery if necessary

□ I disagree to a vacuum delivery

□ I agree to a caesarean section if necessary

□ I disagree to a caesarean section

□ I want ___________________ to have medical proxy over myself and baby in an emergency

Caesarean Birth

□ Photos

□ Spinal Block

□ General Anaesthesia

□ Partner/Support Person Present

□ Lowering of drape for the birth

□ Clear Drape

□ Describe the procedure as it occurs

□ Pull own baby from stomach

Following Birth

□ Immediate Skin to Skin

□ Delayed Cord Clamping

□ I want to cut the cord

□ I want my partner to cut the cord

□ I want selected support person to cut the cord: _________________________

□ I agree to an injection to speed up placenta delivery

□ I disagree to an injection to speed up placenta delivery

□ I want to donate my placenta to science

□ I want my placenta to be encapsulated

□ I want to take my placenta home

□ I want the hospital to dispose of my placenta

□ I agree to the vaccine injection

□ I agree to the vaccine orally

□ I disagree with the vaccine___________________________


□ Exclusively Breastfeeding

□ Exclusively Pumping

□ Mixed Feeding

□ Exclusively Formula

□ I agree to my child being given a pacifier

□ I disagree with my child being given a pacifier

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