Birth Plan Form

MBBS MD FRANZCOG DDU (ASUM)

Patient Registration

Patient Name *

Title

First *

Last *

Date of Birth *

Contact Number

Birth Partner's Name *

Title

First *

Last *

Date of Birth *

Contact Number

Due Date *

Name of obstetrician / midwife *

Other birth-support (doula / other family)

Labour and Birth

Mobility during labour

I would like to keep active during labour if possible (walking, fitball, etc.)Mobility is not important to me

Do you want to use any special facilities?

BathOther

Please specify

Foetal Monitoring

Continuous monitoring (will mean limited mobility)Intermittent monitoring

Vaginal / Cervix Examinations

I would like minimal examinationsI am happy for examinations as deemed necessary by medical staff

Pain Relief

Do not offer; I will ask if I want pain reliefOffer if I appear uncomfortableOffer as soon as possible

Episiotomy

I do not want an episiotomy unless there is a real needI would like an episiotomy to reduce the risk of tearing

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through.

Delivery

I would like to touch the baby's head when it crownsI would like a mirror available to view pushing / crowning / birthOther

Please specify

Immediately following delivery

I want the baby placed on my chest immediately after birth (skin to skin)Please delay cord clamping and cuttingI would like my birth partner to cut the cordI would like to cut the cordBirth partner does not want to cut the cordI want to bank cord blood privately (stored)

Caesarean

Birth partner presentScreen lowered at deliverySkin to skin as soon as feasibleOther

Please specify

In the event that a caesarean section is deemed necessary, I would like the above.

Baby Care

Feeding Baby

I wish to breastfeed exclusivelyI wish to breastfeed, but formula supplementation is acceptableI wish to formula feedI do not want baby to be given a pacifierI would like to meet with a lactation consultant

Vitamin K

I would like my baby to have the single injection of Vitamin K

Hepatitis B

I would like my baby to be vaccinated with Hepatitis B vaccine before discharge

Any special dietary requirements for the new mum?

Any other special needs for the new mum and / or birth partner (language, religion, disability, etc.)?

Length of stay in hospital

I would like to have as short a stay as possible in hospitalI would like to stay in hospital for 1-2 days after the birthI would like to stay in hospital for more than 2 days after the birth

Your Signature *