Births and Beyond

Birth Plan

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Name                                                               Partner's Name

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Street Address             Town/City               Zip Code              Telephone ( H )                (W)

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Doctor/Midwife's Name                            Due Date                Baby's Name (if chosen)

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Your Labor Support People __________________       Family Members  ___________________

Do you want visitors during labor?  Yes__  No__     Are you planning a Doula-assisted birth?_____

Important Requests_________________________________________________________________

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Relieving Pain____________________________________________________________________________
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Concerns_or Fears___________________________________________________________________________

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Delivery_________________________________________________________________________
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Special Deliveries_______________________________________________________________________

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Cesarean_Birth___________________________________________________________________________

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Discharge_______________________________________________________________________
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Infant Feeding

            Breast___

                        Do you have previous experience breastfeeding?  Yes__ No__

                        Do you plan to return to work while breastfeeding?  Yes__ No__

            Bottle___

                        Do you have previous experience with formula feeding?  Yes__ No__

                        Is there a certain kind of formula you plan to use?  Yes__ No__

Newborn Care

Have you had experience with newborns?  Yes__ No__ If yes, please explain_________________
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