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 EXAMPLE BIRTH PLAN
 
 Enter your name in the space provided below.
 
 
  
 
 
 Your Birthing Partner(s)
 
 
  
 
 
 Midwife and/or Obstetrician
 
 
 
 
 
 Name of Hospital or Birthing Center
 
 
  
 
 
 Paediatrician
 
 
  
 
 
 Enter the approximate due date
 
 
DATE 
 
 

-

 

-

 
 
 
 
 During my pregnancy I have had
 
 

Symphysis pubis dysfunction

  

One sided sacroiliitis

  

Pelvic Girdle Pain
 

Diastasis Symphysis Pubis

  

Doubled sided sacroiliitis

    
 

Other:
 
 
 The following movements have become difficult to do an/or sustain
 
   standing    going to work    cleaning the house
   lifting    sitting    cooking meals
   walking up stairs    carrying    driving a car
   lying on my back    walking down stairs    shopping for groceries
   caring for my other children
   other:
 
 Guideline for pain level
 
    I cannot stand
    I cannot walk
    I can't walk more than 3 meters/ 10 feet
    I am in mild pain most of the day
    I am in moderate pain most of the day
    I am in severe pain most of the day
    I am in disabling severe pain most of the day
    Other:

 I would like my environment to have
 
    Dimmed Lights
    To have Voices Respectfully Lowered
    Include Music I Provide
    Include Coping Aids for Pelvic Pain...special pillows etc.....
    Other:
 
 I would like to wear my own clothing
 
 
Yes
 
No
 
 
 

I would like my birthing partner(s) to be able to film and/or photograph at my request

 
 
Yes
 
No
 
 
 
 I would like to keep internal vaginal exams to a minimum
 
 
Yes
 
No
 
 
 
 I would prefer not to have my pubic hair shaved because of the symphysis pubis pain
 
 
Yes
 
No
 
 
 
 I would like some privacy to discuss my pain-relief options before I make a decision
 
 
Yes
 
No
 
 
 
 Only offer me medication when I ask
 
 
Yes
 
No
 
 
 
 Please suggest medications if you see I am uncomfortable
 
 
Yes
 
No
 
 
 
 I would like to try these non-medical therapies
 
    Massage
    Guided Relaxation
    Water [shower/bath]
    Hot/cold therapy
    Acupressure
    Other:
 
 If available I would like to use the following
 
    Allowed freedom of movement
    Walking epidural
    Classic Epidural
    Birthing Bed
    Birthing Stool
    Birthing Chair
    Birthing Pool/Tub
    Other:
 
 Positions I would like to try During the Pushing and Delivery
 
    Side lying position with some one supporting my knee
    Kneeling resting arms on bed/chair
    Semi-reclining on bed, knees pressed to chest with some one helping to stabilize my knees
    Other:
 
Squatting or lying on my back with my legs in stirrups aren't the best positions for me to be in because of the pelvic pain or other :
 
 
 

 

 

 
 
 If I require stitches I would prefer not to have my legs in stirrups because 
 
 
 

 

 

 
 
 After the delivery I may require total bed rest because my ability to move around is
 
    Bad
    Poor
    Average
    Fair
    Good
 
 Due to my pelvic pain, after the delivery I might require the following
 
    Pain medication
    Longer stay in hospital
    Physiotherapist
    Pelvic binder or belt
    Options and care from other specialist's
    Other
 
Before I go to the Maternity Ward I will need you to make sure the ward staff are
aware of my pelvic joint pain and will assist me with receiving treatment for my
unstable pelvis and organize the necessary aids to help make me more mobile...
add more if necessary