Informed Choice Birth Plan

Instructions: Check all that apply! Don’t know what that means or if it should be considered for your birth plan? Have questions? Have special instructions or notes? Leave them in the comment boxes so we can discuss!

During the birthing process, it's important to me: *

I give consent to: *

None, unless medically necessary with consent Artificial rupture of membranes Augmentation of labour (ie; Cervidil or Oxytocin) IV insertion Nitrous Oxide (Laughing Gas) Narcotic Analgesia (ie; Morphine or Fentanyl) Epidural Analgesia Medical/Nursing students involved/observing

My wishes and consent are: *

My wishes are: *

Delayed cord clamping Preserve cord blood for private banking I plan to donate cord blood (BC Woman’s Only) We'd like to preform a burning cord ceremony The person we'd like to cut the cord is:

My wishes are: *

Allow spontaneous delivery of placenta I would like to see my placenta I plan to keep my placenta I plan to encapsulate my placenta

Newborn Interventions and Routines:

My wishes and consent are: *

Breastfeeding I would like hands-on Doula support with breastfeeding Donor milk (if required) Formula/Bottle feeding

Thank you for completing this form! Don't worry if it brought up a lot of questions! For my Doula clients, we can go over them at one of your prenatal meetings!

*Please note: As your doula it my role to educate, prepare, and support woman before and during the birthing process. Due to the nature of birth, or unforeseen circumstances, a perfect plan can change. Creating this "Informed Choice Birth Plan" is not a guaranteed outcome.

Informed Choice Birth PLan

Informed Choice Birth Plan