Fillable Printable Sample Birth Plan Checklist

Sample Birth Plan Checklist

Birth Plan

We encourage you to write down your wishes and desires for the birth and to discuss these with your physician. (Use

additional sheet, if necessary)

Your support People:

Your preferences about pain control:

Medical interventions during labour:

Second stage and delivery:

Most important issues:

Concerns or fears:

Infant feeding:

Newborn Procedures:

THE BIRTH PLAN HAS BEEN REVIEWED AND DISCUSSES WITH ME.

Patient’s signature:

Health-care provider’s signature: