Birthing Plan Form

Either fill out the form below, or download the form by clicking here and you can print it and fill it out offline.

    Birth Preference List Summary



















    Where do you want to give birth?

    Before Labour Begins






    If I choose, I would prefer to try the following induction techniques first:







    The Following Are to Be Used Under the Guidance of Midwife





    If Medical Induction Becomes Necessary




    If My Waters Release Before I Go Into Labour



    Environment












    If Birth Equipment Is Available, I Would Like to Use






    Pain Relief




    I am prepared to try the following natural and alternative methods:

















    Please number in order of preference.

    If I Choose to Use Drugs, My Preference Is

    Nitrous Oxide (gas)

    Morphine

    Epidural

    Spinal

    General Anaesthetic

    Other Considerations




    Monitoring in Labour (Discussed)






    Vaginal/Cervix Examinations (Procedure Discussed)


    Membranes/Waters




    Labour Positions







    Pushing



    To Maximise Perineal Stretch







    Other Labour Considerations Discussed







    The Delivery of Baby








    After the Baby Is Born




    Caesarean








    Third Stage Labour/Delivery of the Placenta




    Placenta/Whenua







    Newborn Procedures











    Guthrie – Heel Prick Test (Newborn Metabolic Screening)



    Breastfeeding










    Length of Stay in the Birthing Unit or Hospital


    Important Considerations for Care