Visual Birth Plan – Voices of Eve

My name *

My e-mail address *

This will be for billing and general communication through your pregnancy and through the postpartum period.

My phone number *

My partner's phone number

Name of anyone else attending you at your birth and their relation to you *

Any other legal names that may be used by our birthing place *

There have been times when I was delayed getting to a client because their hospital had their maiden name instead of their married name on file.

Baby's name/gender

Estimated Due Date *

Home Address

This is used for if Abbey will serve you at home before going to the birthing place or if you are having a homebirth.

Birth Place location

Address if you can or a name that Abbey can search for

Any additional emotional or mental needs?

some examples may be that you struggle through depression, anxiety, or recovering from an addiction.

Birthing Location

Birth Center
Operating Theater Birth
Home birth
Hospital Birth

My Personal History

My Birth is Planned as...

Care Provider Choices

How I am Feeling About the Birth

I am feeling...
I am feeling...
I am feeling...
I am feeling...

My Birth Environment

Spiritual and Cultural Aspects of My Birth

I have a spiritual requirement
Special requirement
Special cultural requirement

Coping Strategy

Augmentation preferences

Cervical Examinations

Regular Routine Cervical Examinations
Negotiate consent for examinations
Limited Cervical Examinations
I can check my own cervix
Cervical examinations by maternal request
Ask permission, my consent is important

Monitoring the baby

I request constant fetal monitoring
No fetal scalp electrode
I choose intermittent monitoring

Pushing choices

Placenta Choices

First Hour

Catching the baby

_____ to catch the baby (family member, doula, etc.)
Dad to catch the baby
Mum catch the baby
Care provider to catch the baby
Let me discover the baby's sex
Let us discover the baby's sex

My choices for my baby

Choices in the event of a C-section

Any other specific preferences I have that is not on this list

Abbey might be able to create a visual option if there is something else that you want specifically adress that is not already on the list.

How comfortable are you with the half hour rule? When you ask for an epidural or other medical pain management will you try to give me half an hour to try other methods before choosing the epidural? *

Yes, I like that plan!
I am comfortable with chemical pain management
I would like more information before answering

a lot of the time the pain is most intense during a transition. For example maybe you are going from 4-6 cm or baby is moving further down. Those transitions can be intense and if we can work through some position changes or adjustments to the environment it can make a big difference in delaying or avoiding chemical pain management if you are hoping for a natural labor.

Please list any medical needs, allergies, or dietary restrictions *

Sometimes your records are incomplete or don't have time to transfer and if a birth happens fast I can help make sure that the staff is aware.

What do you most desire for Abbey's role as your doula *

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