Free Birth Plan Template 25
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your birthplan
Putting pen to paper can help you
and your midwife understand
what matters to you most

www.boots.com/parentingclub

1

The name I would
like to be called is:

__________________________________

4

2

My preferred birth partner
would be:
_________________________________
who is my ________________________

3

I am happy to be photographed/
videoed during labour
by my birth partner:
® Yes
® No

5

During labour I would like
the following pain relief:
® A bath/Shower
® Breathing techniques
® Massage
® TENS machine
® Gas and air
® Pethidine
® An epidural
I would like to use the following
during labour:
® A birthing ball
® A birthing pool
® A birthing stool
® Beanbags
® Music

6

My preferred positions
in labour are: _________________
__________________________________
__________________________________

7
8
9

I am happy to have students
present:
® Yes
® No
I am happy to have my baby’s
heartbeat continually monitored:
® Yes
® No
I would like to be in the following
position