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Birth Plan

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BIRTH PLAN

Information about the mother

Name of the mother:

the field is mandatory

Name of the partner:

Name of the companion/doula:

Due date:

the field is mandatory

Chosen team/hospital/midwifes:

the field is mandatory

Stem cells bank:

the field is mandatory

Other notes about the mother ()

General requests

I prefer to avoid

I would like

Other

First period

Mobility

Food and beverages

Monitoring

Pain relief

Other

Labor augmentation

Other

Second period

Delivery

Other

Episiotomy

Third period

I prefer

Umbilical cord to be

Other

I would like to

I would like to hold baby

About the baby

Medical exam and procedures

Other

I would like to breastfeed

Other

Separation

I would like baby to stay in my room

Other

Care

Baths to be given

Please don't give baby

Other

If a C-section is necessary, I would like

Other

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