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Birth Plan

This document outlines a birth plan for an expectant mother. It collects information about the mother and husband, including their names, ages, and contact details. It designates a navigator to assist them. It documents the mother's health goals during pregnancy and plans for delivery location. The second part is for a health provider to fill out with details of prenatal visits. The plan aims to prepare the couple for pregnancy, birth, and newborn care by documenting important health information, birth preferences, and necessary documents.

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Ann Camille Rosales
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125 views2 pages

Birth Plan

This document outlines a birth plan for an expectant mother. It collects information about the mother and husband, including their names, ages, and contact details. It designates a navigator to assist them. It documents the mother's health goals during pregnancy and plans for delivery location. The second part is for a health provider to fill out with details of prenatal visits. The plan aims to prepare the couple for pregnancy, birth, and newborn care by documenting important health information, birth preferences, and necessary documents.

Uploaded by

Ann Camille Rosales
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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BIRTH PLAN

Part I : To be filled out by the couple with the assistance of the navigator
Name of Mother : Age :
Name of Husband : Age :
Name of Navigator : Family No. :
Referred to Health Provider : Scheduled date of consult : Reason for referral :
A (MM/DD/YY) [ ] For Pre-Natal
Services
[ ] For Post Partum
Care
[ ] For Newborn Care
Health Goals : (pls. check) To have baby delivered by : Where to deliver the baby :
[ ] to have monthly pre-natal [ ] Physician [ ] Hospital
check-up (atleast 4 visits); [ ] Nurse [ ] Lying – in / Birthing
[ ] atleast 1 visit during the [ ] Midwife Home
1st trimester; [ ] Other health facility
[ ] atleast 2 visits in the 3rd
trimester
To receive PostPartum Care: [ ] To have our baby receive [ ] others, pls. specify
B [ ] with atleast 2 visits newborn screening
(1st visit within 24 hrs.
2nd visit within one
week after delivery)
[ ] one clinic visit within
4-6 weeks post
Delivery
[ ] To receive Family Planning counselling / services
Part II : To be filled by health provider ( midwife, nurse or doctor )
Provider for Prenatal / Postpartum Care : Date of 1st Prenatal Visit : _________________
Date of 2nd Prenatal Visit : _________________
C Date of 3rd Prenatal Visit : _________________
Date of 4th Prenatal Visit : _________________
PLEASE FILL OUT ALL SECTIONS OF THE MOTHER & CHILD BOOK, to include :
 Birth Plan ( page 13 in the Mother & Child Book
Who will deliver my baby? Where will I deliver? How much should I prepare ?
[ ] Physician [ ] Hospital
[ ] Nurse [ ] Lying – in / Birthing Home
[ ] Midwife [ ] Other : ______________
Who will accompany me? Who will take care of the
D [ ] Husband children?
[ ] Mother [ ] Husband
[ ] Others : _____________ [ ] Mother
[ ] Others : ______________
 Other relevant information about the pregnancy preparation and special concerns
 Preparation for giving birth
 Warning signs during pregnancy
Philhealth Claims, if applicable
E  Prepare documents needed

EXPECTED DATE OF COMPLETION OF THIS PLAN : _______________________________

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