Birth Plan Worksheet 1Birth Plan Worksheet 1Birth Plan Worksheet 1
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Birth Plan Worksheet
NAME: ______________________________________________________________________

I'd like the following people to be present during labor and/or birth:
Partner: ___________________________________________________________
Friend/s: __________________________________________________________
Relative/s: _________________________________________________________
Doula: ____________________________________________________________
Children: __________________________________________________________
I'd like to:
bring music
dim the lights
wear my own clothes during labor and delivery
take pictures and/or video during labor and delivery
I'd like the option of returning home if I'm not in active labor.
Once I'm admitted, I'd like:
my partner to be allowed to stay with me at all times
only my practitioner, nurse, and guests to be present (i.e., no residents,
medical students, or other hospital personnel)
to wear my contact len