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My Birth Plan
First name
Email
Partners/Fathers First name
Last name
Due Date
My partners Email
I know the sex of my baby
No
Yes
My baby is a
girl
boy
Twins
Rather not say
I would like to Birth at home?
No
Yes
I would like to Birth in Hospital
No
Yes
I would like a water birth
No
Yes
I am undecided!
No
Yes
Notes for the Midwife
Pain Relief Options Chosen
I would like an epidural
No
Yes
I would like Gas & Air
No
Yes
I would like a Opioids
No
Yes
I would like no pain relief
No
Yes
Notes for the Midwife
Birth Support
I would like my partner present
No
Yes
My Doula will be present
No
Yes
Notes for Midwife
Birth
Baby to have Vitamin K ?
No
Yes
I would like Skin to skin
No
Yes
Delayed Cord Clamping
No
Yes
I would like to Breastfeed
No
Yes
My partner wants Skin to skin
No
Yes
Myy partner wants to cut the cord
No
Yes
I declare that the info I’ve provided is accurate & complete
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