Pregnancy Plan English

About Me

Full Name

Maiden Name

Address

E-mail

Contact Person and Phone Number

Name of Companion at Birth (if accompaniment is planned)

Due Date

Blood Group and Rh Factor of Mother

Which pregnancy is this (first, second, etc.)

Weight at the Start of Pregnancy (kg)

Current Weight (kg)

I am a smoker

Past illnesses

Description of past illnesses:

Past surgeries

Description of past surgeries:

I have allergies

List of allergies:

I am taking therapy

Description of therapy:

Macedonian is not my mother tongue, and I need someone who speaks my mother tongueI need a translatorI am a person with a disabilityI have special dietary needsI want certain religious customs to be respected during childbirthI have another special need

If you have another special need, specify here:

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Place of Birth

Choose how you want to give birth. Talk to your chosen gynecologist or midwife about the options available in your city or region and how your health affects the choice.

I want to give birth in a maternity ward (hospital)I want a natural birthI want a natural and painless birth (with analgesia)I want a water birthI want a cesarean section

Admission to Maternity Ward

At admission, the staff will ask you several questions, although most of the information is already recorded in the pregnancy booklet. To make the process easier, you can list some of them here. The questions vary by institution.

If I am not in active labor, I want the option to go home and waitAt admission, I DO NOT WANT an enemaAt admission, I DO NOT WANT pubic hair shavingAt admission, I DO NOT WANT an IV line (cannula), unless medically necessary

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Companionship During Childbirth

The presence of a trusted person is of great benefit. This can be a partner, parent, sister, friend, doula, or another person with whom you feel safe. Companionship is not allowed during a cesarean section.

I want to have a companion during childbirth

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My Wishes and Needs During Childbirth

If childbirth progresses normally and without complications, I want:

To listen to music (with headphones or phone)Dimmed lightingPeace and quietMy companion to take photos/videosUse of mobile phone for video callsTo wear glasses/lensesTo eat and drink as needed (if allowed by medical staff)To move and choose positionsHealthcare workers to introduce themselves by nameTo be fully informed before any interventionNo additional observers (students)

In the first stage of labor I want to:

Move in and out of bedUse a ballShowerHot water bathLying positionHave as few vaginal exams as possible

Something else:

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Childbirth

In the second stage (pushing), I want:

Option to change bed positionWater birthApplication of perineal protection methods (no episiotomy unless medically justified)Instinctive pushing, without instructions, unless necessary

Acceleration of Childbirth

I do not want acceleration unless medically necessaryI do not want artificial rupture of membranes unless necessaryI do not want oxytocin drip unless necessary

Pain Relief Methods (Natural):

For pain relief I want to use the following methods:

Free choice of positionBallShower/bathBreathingCold compressesWarm compressesMassageSuggestions from midwife

Another method:

Medicines

Pain relief medicines (choose one):
I will ask clearly if I want medicine; do not offer without requestI want to use painkillersEpidural analgesia

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Cesarean Section

It is important to plan for a cesarean section.

During the cesarean section, I want:

General anesthesia (sleep)Spinal/epidural anesthesia (awake)Music of my choice, agreed with staffSilence at birthTransparent or lowered curtainBaby visible at first checkOne hand free to hugSkin-to-skin contact in the operating roomBaby placed on my face immediatelyA few photos by midwife/staffIf I cannot, companion to have skin-to-skin contact

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After Childbirth

After vaginal birth I want:

Immediate receipt and holding of babyTo discover the baby’s sex myselfImmediate skin-to-skin contactUninterrupted 'Golden Hour' (bathing/interventions can wait)Delayed cord clampingTo see the placentaTo take the placenta home (if allowed)Pediatric exam while baby is on me

Third Stage (Placenta):
I want natural expulsion without drugsI want use of drugs for faster expulsion

Cutting the Umbilical Cord:
I want to cut it myselfI want my partner/companion to cut itI want the staff to cut it

Cord Blood:
I want to store (with prior agreement)I do not want to store

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Baby Nutrition and Care

Breastfeeding:
I plan to exclusively breastfeedI want to give only colostrum, but not continue breastfeedingI do not want to breastfeed

If supplementation is needed:
I want to first try breastfeeding/expressed milkI want supplementation with formula/glucose using alternative methods (cup, syringe)

Additional wishes:
I want help with breastfeedingI do not want formula without my consentI want to be present at all procedures (bathing, tests, changing)

After Cesarean Section:

I want to be with my baby as much as possibleI want to participate in care (feeding, changing)

If I cannot breastfeed:
I want my baby to receive donor human milk

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End

After completion, the answers are saved in a PDF document which is sent to the entered email and to the hospital. It is also possible to download the document manually.

Declaration:

With this Birth Plan I have listed my wishes. I am aware that childbirth can be unpredictable and that medical changes to the plan may be made if necessary, in order to protect the health and safety of myself and my child.

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