Name:
Address:
My Due Date:
Contact Phone Number (in case of emergency):
List any pre-existing Allergies, Conditions or Medications:
My Birth Partner(s) will be:

I would like my baby's birth environment to be kept as quiet and low key as possible.
I would prefer to be vaginally examined only when absolutely necessary.
I want to remain as mobile as possible during my labour.
I would prefer only to have an IV drip if I become dehydrated.
I would like to be allowed to drink fluids at will during the first stage of my labour.
I would like to listen to my own choice of music during labour.
I would like the lights dimmed during my labour, particularly when my baby's head is crowning.
Other Requests:

Foetal Monitoring

I do not wish to have continuous foetal monitoring unless required.
I do not want an internal monitor placed on my baby unless absolutely necessary.
Other Requests:

Induction of Labour

I do not wish to have the amniotic membrane ruptured artificially unless absolutely necessary.
If my labour is not progressing sufficiently, I would like to have the amniotic membrane ruptured before other methods of induction are used to speed up my labour.
If my labour progresses slowly I want to try changing my birthing position and other natural methods such as walking around and nipple stimulation before drugs are administered to speed things up.
Other Requests:

Pain Relief

I am aiming to give birth without the use of any pain relief.
I would like to use gas and air for pain relief during my labour.
I would like to use pethidine for pain relief during my labour.
I would like to use a TENS machine for pain relief during my labour.
I would like to try hypnosis for pain relief during my labour.
I would like an epidural for pain relief.
I would like to have a standard epidural.
I would like to have a mobile epidural.
Other Requests:

C-Section

I have requested a C-section.
Unless necessary, I would like to avoid a C-section.
If a C-section is unavoidable, I would like to be kept informed about the reasons as to why this is the case.
I would like ..........................(birth partner) present at all times if the baby is delivered by Caesarean.
I would like to remain conscious during my C-section, if possible.
I would like the screen lowered just before the birth of my baby so that I have an opportunity to see him or her immediately.
If my baby is not distressed, please pass him or her to (birth partner) immediately after birth.
Other Requests:

Perineal Care

I wish to avoid having an episiotomy (surgical cut) unless it is believed necessary for the safe delivery of my baby.
I would prefer a natural tear in preference to an episiotomy.
I would like a local anesthetic to be administered before repairing any damage to my perineum.
Other Requests:

Delivery

I would like to be allowed to choose my preferred birthing position.
I would like the lights to be dimmed during the actual delivery.
If required, I would like ..........................(birth partner) and/ or midwifes to offer physical support to me during the pushing stage.
I wish to use a mirror so I can see my baby's head when it crowns.
I would like the opportunity to feel my baby's head as it crowns.
I would like to wait until I feel the urge to push before beginning the pushing phase of my labour.
I would like the room to be as quiet as possible when the baby is being born.
I want my baby placed on my stomach/ chest immediately after delivery.
I do not want my baby to be cleaned before I hold him/ her.
Other Requests:

After the Delivery

I would like to have ..........................(birth partner) cut my baby's umbilical cord.
I would like to cut the cord myself.
Please wait until the umbilical cord has stopped pulsating before allowing it to be cut.
If possible, I wish to hold my baby whilst I deliver the placenta and whilst any tears are being seen to.
I would like to be given the chance to hold my baby before (he/she) is weighed or examined.
I would like to see the placenta as soon as it is delivered.
I plan to keep my baby with me after his/ her birth and would prefer if any examinations were carried out with the baby on my abdomen.
If my baby needs to be taken away for medical treatment, (birth partner) will accompany him/ her.
I am happy for my baby to receive Vitamin K after the birth.
I would prefer my baby did not receive Vitamin K (discuss the implications of this decision with your midwife and consultant).
If my baby is cold I wish to be given the opportunity to practice skin-to-skin care rather than having him/her placed under heat lamps.
I want to deliver the placenta naturally and without the aid of drugs, unless absolutely necessary.
I would like to donate the umbilical cord blood, if possible.
I would like to bank the umbilical cord blood, and have made appropriate plans to do so.
I wish to take the placenta home with me.
Other Requests:

After the Birth

If possible, I would like to be given a private room.
I do not wish to be separated from my baby unless absolutely unavoidable.
I would like to practice "rooming in" with my baby.
Other:

Breastfeeding

I intend to breastfeed my baby and would like to do so within 30 minutes of my baby's birth.
I would like my baby to self-attach but if this does not happen then I would appreciate some help getting my baby latched on and getting my positioning correct. I would also like to be shown how to express my breastmilk by hand, how to recognise swallowing, and what to expect from breastfeeding in the days following my discharge from hospital.
I do not want to receive any samples of formula.
I do not want any bottles given to my baby (including formula, glucose water or plain water).
I do not want my baby to be given a dummy.
If there is a medical need for my baby to receive supplementary feeds I wish to be informed as to the reasons.
If I am separated from my baby for medical reasons I would like to use a breastpump to express milk.
I would appreciate receiving information about breastfeeding, breastfeeding resources and support groups.
I would love the opportunity to meet and chat to breastfeeding support staff.
Other Requests:

Recording my Labour

I would like ..........................(birth partner) to take photographs during my labour and/ or the birth of my baby.
I would like ..........................(birth partner) to make a digital recording of my labour and/ or the birth of my baby.
Other Requests:

Other Requests

I am happy for medical students to be present during my labour and/ or the birth of my baby.
Other Requests:

Birth Plan provided by www.BreastfeedingMums.com