Sample Birth Plan

Name of Expectant Person:

I identify by the pronoun:

My support person’s name:

My support person

identifies by the pronoun:

Name of my Healthcare Provider

who cared for me during pregnancy:

Baby’s Due Date:

Sample

Birth Plan

Please note the content of this document is intended to give you an idea of

questions/ideas/suggestions that could form part of your Birth Plan and is not intended to

replace any documentation provided by your Healthcare Provider and/or delivering hospital.

Here are some things I would like you to know about me/us

(Previous experiences, fears, concerns):

I am pregnant with:

One baby Multiples (twins)

... / ... / ...

I / we have attended:

Prenatal Classes

Breast Feeding Classes

Newborn Care Classes

Emergency First Aid Classes

Markham Stouffville Services Buiding• Suite 403, 379 Church Street, Markham, ON, L6B 0T1

905-294-BABY(2229) www.markhamprenatal.com

Markham Stouffville Services Buiding• Suite 403, 379 Church Street, Markham, ON, L6B 0T1

905-294-BABY(2229) www.markhamprenatal.com

Pain management

I would like a medication free birth

I would like to see how things go and make a decision about pain relief

dependent on my labour

I would like to have pain medication as soon as it is available to me

Comfort measures I would like to try:

Listening to music that I have brought with me

Dim Lights

Use a mirror to watch see the baby crowning

I am open to trying different positions to cope with labour such as Hands &

Knees / Exercise Ball / Walking

Bath/shower

Breathing & relaxation or meditation exercises that I have practiced

After my baby is born

My support person would like to cut the umbilical cord (if possible)

I will do skin to skin with baby but if I am unable then

will do skin to skin

I would like to collect the baby’s cord blood/ tissue and have brought the kit

and completed the paperwork

I would prefer to delay the baby’s first bath and do it myself at home

Name of the Doctor who will care for my baby:

Notes:

Markham Stouffville Services Buiding• Suite 403, 379 Church Street, Markham, ON, L6B 0T1

905-294-BABY(2229) www.markhamprenatal.com

Newborn feeding plan

I plan to exclusively breastfeed and will only give supplement if medically

necessary

I am planning on pumping my breast milk and feeding the baby with a bottle

I am planning to feed the baby formula

Following Discharge From Hospital

I am aware of community resources once discha

rged

I am aware that I need a car seat for the baby

I had difficulty breast feeding my first baby and would appreciate extra help

this time

Details: