Birth plan

Labour and birth

My preferences are:

Environment

Dim lights

Okay to have training medical staff observe

labour and birth

Doula/birth attendant

Quiet music

Other _______________________________

Position(s) for labour and birth

Tick what your preferred positions are:

Walking

Standing

Squatting

Sitting

Kneeling

Lying down

Birth stool

Floor mat

Other

Mobility during labour

I would like to keep active during labour if possible

(walking, birth ball, etc.)

Rest on the bed/ﬂoor mat/birth ball as needed

Relaxation and comfort during labour

Massage

Bath/birth pool

Shower

Fit ball

Bean bag

Warm towels/packs

Cool towels/packs

Acupressure

Hypnotherapy

Other

Birth plan

tummytalks.com.au

Mum’s details

Name Contact number

Email address

Birth Partner’s name Contact number

Due date

Name of Obstetrician/Midwife

Other birth support (Doula/other family/friend) Blood type

Where do you want to give birth?

Hospital:

Birth Centre:

At home

Not sure yet

Birth plan cont.

tummytalks.com.au

I would like to discuss the following with my midwife

or obstetrician prior:

Vaginal/cervix examinations

Pain relief (gas/air, pethidine, epidural,

TEMS machine, water)

Episiotomy

Assisted delivery (Forceps, Ventouse, Caesarean

section)

Artiﬁcial breaking of waters

Foetal monitoring

Hormone drip

Urinary catheter

If all is well with you and baby:

I would like to touch baby’s head when it crowns

I would like a mirror available to view pushing/

crowning/birth

I want my baby placed skin to skin on my chest

immediately after birth

I would like my birth partner to cut the cord

I would like to cut the cord

I want to bank cord blood privately

Baby Care

Feeding Baby

I wish to breastfeed exclusively

I wish to breastfeed, but formula supplementation

is acceptable if medically indicated

I wish to formula feed

I do not want baby to be given a paciﬁer

Vitamin K/Hepatitis B vaccination

I would like my baby to have the single injection

of Vitamin K

I would like my baby to have oral Vitamin K

I would like my baby to be vaccinated with

Hepatitis B vaccine before discharge

Any special dietary requirements:

Any other special needs for new Mum and/or birth

partner (language, religion, disability, etc)

Umbilical Cord Blood and Tissue Banking:

I am collecting and storing my baby’s cord blood

(Private Banking) with

Name:

Signature:

Date:

Healthcare Provider’s Name:

Healthcare Provider’s Signature:

Date: