Sample Birth Plan Template

I will bring a:
Birthing stool
Birthing chair
Squattng bar
Birthing tub
During delivery I would like to:
Squat
Semi-recline
Lie on my side
Be on my hands and knees
Stand
Lean on my partner
Use people for leg support
Use foot pedals for support
Use birth bar for support
Use a birthing stool
Be in a birthing tub
Be in the shower
I would like an episiotomy:
Used only after perineal massage, warm
compresses and positioning
Rather than risk a tear
Not performed, even if it means risking
a tear
Performed only as a last resort
Performed as my doctor deems necessary
Performed with local anesthesia
Performed by pressure, without local anesthesia
Followed by local anesthesia for the repair
As the baby is delivered, I would like to:
Push spontaneously
Push as directed
Push without time limits, as long as the
baby and I are not at risk
Use a mirror to see the baby crown
Touch the head as it crowns
Let the epidural wear off while pushing
Have a full dose of epidural
Avoid forceps usage
Avoid vacuum extraction
Use whatever methods my doctor
deems necessary
Help catch the baby
Let my partner catch the baby
Let my partner suction the baby
Page 3 of 6
birth plan
Page 3/6
Edit Online
Free Download

Sample Birth Plan Template PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
4 Page(s) | 2065 Views | 17 Downloads
  •  
  •  
  •  
  •  
  •  
3 Page(s) | 1208 Views | 2 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1201 Views | 4 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 1258 Views | 22 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 605 Views | 4 Downloads