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1
The name I would
like to be called is:
__________________________________
2
My preferred birth partner
would be:
_________________________________
who is my ________________________
3
I am happy to be photographed/
videoed during labour
by my birth partner:
® Yes
® No
4
During labour I would like
the following pain relief:
® A bath/Shower
® Breathing techniques
® Massage
® TENS machine
® Gas and air
® Pethidine
® An epidural
5
I would like to use the following
during labour:
® A birthing ball
® A birthing pool
® A birthing stool
® Beanbags
® Music
6
My preferred positions
in labour are: _________________
__________________________________
__________________________________
7
I am happy to have students
present:
® Yes
® No
8
I am happy to have my baby’s
heartbeat continually monitored:
® Yes
® No
9
I would like to be in the following
position to give birth:
® Reclining in bed
® On my side
® Squatting
® On all fours
® Id like to decide at the time
10
My thoughts on having my
waters broken artificially:
__________________________________
__________________________________
11
I would like to:
® Be told when to push
® Push when it feels right
12
My thoughts on having
an episiotomy:
__________________________________
__________________________________
13
I would like my birth partner
to cut the umbilical cord:
® Yes
® No
14
My thoughts on being given
an injection to contract my
womb before the delivery
of the placenta:
__________________________________
__________________________________
15
I would like my baby to be:
® Delivered straight
into my arms
® Wipedrst
16
I would like my baby
to be given Vitamin K:
® Yes
® No
17
I want to feed my baby by:
__________________________
__________________________________
__________________________________
Putting pen to paper can help you
and your midwife understand
what matters to you most
18
My special requests:___________________________________________
_____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
your birthplan
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