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Birth Plan Worksheet 2

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Birth Plan Worksheet 2
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Birth Plan Worksheet
Basic Information
Name: __________________________________________
Partners Name: ___________________________________
Doctor/Midwifes Name(s): __________________________
Other Birth Attendants (doula, friends, etc.): ________________________________________________
_____________________________________________________________________________________
Children and Helpers, if attending: ________________________________________________________
_____________________________________________________________________________________
Babys pediatrician, if known: _________________________________
Delivery location: ______________________________________
Estimated Due Date: ___________________________________
Pre-Birth Preferences
Induction:
___ I prefer to be induced on _____________ (date)
___ I will discuss induction after _____________ (date)
___ I prefer not to be induced unless it becomes medically necessary
___I am having a scheduled c-section on _____________ (date)
Arriving at the Birth Location
___ I will be birthing at home
___ I prefer to arrive as soon as contractions begin or my water breaks
___ I prefer to arrive once my labor is well established
___ I prefer to arrive only once I am advanced in labor; I want to labor at home as long as possible
Paperwork
___ We will pre-register
___ We will do the paperwork at our earliest convenience; please do not separate me from my support
person
___ We will do the paperwork immediately; please make an y separation as brief as possible
Comfort Measures
I would like to use the following comfort measures:
___Pain medication (see below)
___Massage
___Birthing ball
___Birthing tub
___Music
___Essential oils
Birth Plan Worksheet 2
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