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Women's Health | OB/GYN

My Birth Plan


You can’t control every aspect of the labor and delivery process, particularly in the case of a high-risk pregnancy, but having a plan will give you the opportunity to discuss with your obstetrician how you’d like your baby’s birth to be handled. It will not only assist before you go into labor, it will also communicate your preferences to other members of the team such as your labor-and-delivery nurse and your midwife while you’re in active labor.

Complete the short form below and print out a copy to discuss with your healthcare provider at your pre-natal appointment. It's also a good idea to have copies on hand for your file at the hospital and to place in the bag you'll pack for the day of your delivery.


Today's Date
Due Date/Induction Date

My delivery is planned as a/an:

I'd like the following to be present before AND/OR during labor:

During labor, I'd like:

I’d like to spend the first stage of labor:

As long as my baby is doing well, I'd like fetal monitoring to be:

I'd like labor augmentation:

For pain relief I'd like to use:

During delivery I would like to:

Immediately after delivery I would like:

If a C-section is necessary, I would like:

I would like to hold baby:

I would like to breastfeed: join me and the baby:

I would like baby's medical exam and procedures:

Please don't give baby:

I'd like baby's first bath given:

I'd like to:

I'd like my spouse/partner to:

If we have a boy, a circumcision should:

If baby is not well, I'd like:

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