1. No category

Emma Sumner 021366242
Kerry Haslam 0273611215
Michelle Elliott 02102209324
Birth Plan
Name:______________________________ Contact Number:____________________
Birth partner’s name _________________________
Due Date: _________________
Other support people present a birth: _____________________________________
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Where do you want to give birth?
o Hospital
o Home
Labour and Birth
Environment
o Dim lights
o Quiet music (woman must provide)
o Use of swiss ball/ birthing stool if available
o The use of the bath and/or shower for labour
o OK to have student midwives/training medical staff observe
labour/birth
o OK to have student midwives assist under supervision
o Other: ___________________________________________________________-
Emma Sumner 021366242
Kerry Haslam 0273611215
Michelle Elliott 02102209324
I would like a water birth (pool provided by my midwife when possible)
o Yes
o No
Position(s) for labour and birth
o Walking
o Standing
o Sitting
o Lying down
o Kneeling
o Squatting
o Other: ___________________________________________________
Fetal Monitoring
If my labour and birth is low risk my midwife will use intermittent monitoring
However if at any stage of my labour and birth my midwife feels it is
indicated continuous monitoring will be used
Continuous monitoring will also be used for women who are experiencing a
vaginal birth after caesarean (VBAC), induction of labour (IOL), augmentation
of labour or if it is deemed medically necessary for the wellbeing of my baby
Vaginal Examinations
o I am happy for examinations as deemed necessary by my midwife
o I would like minimal examinations
Emma Sumner 021366242
Kerry Haslam 0273611215
Michelle Elliott 02102209324
Pain relief
o Do not offer; I will ask if I want pain relief
o Offer if I appear uncomfortable
o Offer as soon as possible
Nonpharmacological pain relief options
o Massage
o Acupressure
o Water
o TENS machine (woman must provide)
o Hypnosis
o Other
_________________________________________________________________
Pharmacological pain relief options
o Entonox (gas and air)
o Epidural
o Pethidine (only if not in active labour)
Following the birth of my baby:
o I want the baby placed skin to skin on my chest immediately after
birth
o I would like the baby cleaned before being placed skin to skin
o If I am unable to do skin to skin I would like my birth partner to do
this
o Please delay cord-clamping until the cord stops pulsing if possible
o I would like my birth partner to cut the cord
o My birth partner does not want to cut the cord
Emma Sumner 021366242
Kerry Haslam 0273611215
Michelle Elliott 02102209324
o I would like to birth the placenta naturally without medication
o I would like an injection to assist with the delivery of the placenta
o I understand that if it is deemed medically necessary I will be given
a drug to assist with the delivery of the placenta
o I wish to keep the placenta
o If I cannot be with my baby I would like my birth partner to be with
my baby at all times
o Other: __________________________________________________________
Feeding Baby
o I wish to breastfeed my baby exclusively
o I wish to formula feed my baby
Length of stay in hospital
o I would like to stay 1-2 days after the birth of my baby
o I would like to go home as soon as possible after the birth of my
baby
oI
understand that in the event of a caesarean section the usual
length of stay is 3-5 days
Any religious or cultural needs:
______________________________________________________________________
______________________________________________________________
Your signature __________________________ Date_______________
Midwife’s signature_______________________ Date ______________
Emma Sumner 021366242
Kerry Haslam 0273611215
Michelle Elliott 02102209324
Anything else you would like to add: