My Birth Plan
This is your chance to create a birth plan that really suits your needs. You don't have to complete every section, but I've included all the things you should consider.
Who's Who
Your name, who's supporting you & their relationship to you.
Giving birth
Person 1 supporting me
Their relationship to me
Person 2 supporting me
Their relationship to me
Where I would like to have my baby
Home Birth
Labour Ward
Midwifery-Led Unit
Theatre Birth
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My Plans for Labour
My ideal environment and experience
Quiet Please
Physiological Birth
Hypno-birthing
Dim Lighting
Water Birth
Epidural
Open to all analgesia
Free Movement
Instrumental Birth
I wish to avoid an instrumental birth, so consider c-section earlier please
I will consent to an instrumental birth; preferred to c-section
Special Instructions
Explain all procedures to my supporter(s) so I can concentrate
Permission required to check my baby's heart rate at any time
No artificial breaking of waters
I consent to artificial breaking of waters
Pushing
Please help guide me to push
Do not guide me
Perineal Care Bundle
Hands on
Hands off
Medical Students
Yes I am ok with students
No I do not want any students
Vaginal Examinations
Routine vaginal examinations are ok
Vaginal examinations only if requested
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My Plans for Birth
Baby's Sex
We do not know the sex
We are having a
Baby's sex if known
The Cord
Optimal cord clamping
Cutting the cord is
Name of person cutting cord if applicable
Third Stage
Active Management
Physiological
My Placenta
I want to see my placenta please
I do not want to see it
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After Birth
Feeding my baby
I plan to breastfeed
I plan to bottle feed
Our environment
I would like skin to skin at birth
I would like a protected first hour - delay checks and tests, have quiet & dim lighting
Vitamin K for my baby
Injection
Oral
None
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Create My Birth Plan
Would you like a PDF of your birth plan to be emailed to you (£7.99)
Yes please
No thank you (selecting this option will mean you cannot proceed any further)
If yes, please enter your email address
example@example.com
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My Products
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Digital Birth Plan
My Birth Plan PDF from The Modern Midwife
£7.99
£
7.99
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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