Personal Information

Mother's Full Name *

Partner's Name

Expected Due Date *

Preferred Hospital/Birth Centre

Type of Care

NHS Care

Private Care

Mixed NHS/Private

Healthcare Provider Information

Lead Consultant/Obstetrician:

Named Midwife (if applicable):

GP Name:

NHS Number:

Labour Environment & Support

Planned type of delivery:

Vaginal delivery

Planned Caesarean section

VBAC (after previous C-section)

Flexible based on circumstances

Who would you like present during labour?

Partner/Spouse

Doula

My Mother

Close Friend

Other (please specify)

Preferred atmosphere during labour:

Quiet environment

Background music

Dimmed lighting

Aromatherapy/essential oils

Maximum privacy

Mobility during labour:

Want to remain mobile/active

Prefer to labour in bed

Flexible/no strong preference

Pain Management

Pain relief preferences (select all you're open to):

Epidural

Gas and air (Entonox)

Pethidine injection

Water birth/birthing pool

TENS machine

Massage

Breathing techniques only

Prefer natural methods only

Additional pain management preferences or concerns:

Delivery Preferences

Birth positions you'd like to try:

Upright positions

Squatting

Hands and knees

Side-lying

Traditional lithotomy

In water

Episiotomy preference:

Prefer to avoid unless necessary

Okay if recommended

Please discuss before proceeding

If assisted delivery becomes necessary:

Prefer forceps

Prefer ventouse

No preference - doctor's choice

Prefer C-section over assisted delivery

Monitoring & Interventions

Fetal monitoring preferences:

Continuous electronic monitoring

Intermittent monitoring with handheld Doppler

Wireless monitoring (if available)

Medical team's discretion

If induction of labour is recommended:

Accept if medically advised

Want full discussion of options first

Prefer to avoid unless urgent

Artificial rupture of membranes (breaking waters):

Okay if recommended

Please discuss first

Prefer to let happen naturally

Third Stage of Labour & Recovery

Delivery of placenta:

Active management (injection to speed up delivery)

Physiological (wait for natural delivery)

Discuss options at the time

Placenta inspection:

I would like to see the placenta

No need to show me

I want to take placenta home

If perineal repair is needed:

Local anaesthetic

Gas and air for pain relief

Doctor's choice of pain relief

Emergency Situations

Important: These preferences apply only when there is time for discussion and the situation allows for choice. In true emergencies, medical staff will prioritise the safety of you and your baby.

If emergency Caesarean section becomes necessary:

Partner to be present if possible

Please explain what's happening when possible

Regional anaesthesia preferred if time allows

Prioritise immediate care - discuss later

If baby needs immediate medical attention:

Partner to accompany baby

Keep me informed of baby's condition

Bring photos if I cannot see baby immediately

Resuscitation preferences (please discuss with your healthcare provider):

Immediate Newborn Care

Umbilical cord clamping:

Delayed cord clamping (wait for pulsing to stop)

Immediate clamping

Partner to cut cord

Immediate skin-to-skin contact:

Yes, immediately if baby is well

After initial checks are completed

Partner to have skin-to-skin if I cannot

Vitamin K for baby:

Injection (single dose)

Oral drops (multiple doses)

Decline vitamin K

Discuss options before birth

Initial baby care preferences:

I want to attempt first breastfeed immediately

Baby to stay with me at all times if well

Partner can provide care if I'm unable

Photos/video during birth is okay

Feeding Plans

Feeding intention:

Exclusive breastfeeding

Combination breast and bottle

Bottle feeding with formula

Still deciding

If breastfeeding doesn't go to plan:

Want lactation consultant support

Formula supplementation is acceptable

No bottles/dummies unless medically necessary

Prefer cup feeding if supplements needed

Additional Preferences & Information

Immediate postpartum preferences:

Private room if available

Limited visitors initially

Early discharge if appropriate

Baby to room-in with me

Partner to stay overnight

Religious or cultural considerations:

Relevant medical history or previous birth experiences:

Any other special requests or concerns:

Birth Plan Guide