My Natural Birth Plan

Mother : Nurul Rafhana EDD : 01/05/18

Father : Muhammad Muhiyaddin ObGyn : Dr Zana Zalinda

We’re hoping for a natural childbirth. We understand birth is unpredictable and emergency
may arise. If and when such circumstances arise, we request the least invasive treatment
possible and informed consent before interventions.

CTG monitoring only up to two
times (upon admission and if
any need arises). No more than
20 minutes for each session.
Vaginal examinations only up to
two times (upon admission and at
the moment of going into 2nd
stage of labour to be brought to
labour room).
Curtains closed, noise reduced, lights
dimmed, to allow background
quranic recitation to be played. Max
of 2 staffs (doc and nurse) and
partner to be in labor room.

To be able to have meals, drink,
walk, exercise, bounce on
birthing ball uptill the point of
labour.
To not offer artificial rupture of
membrane (AROM) / membrane
sweep.
To avoid episiotomy unless
absolutely necessary.
To not offer any pain relief
medications or IV unless asked
for/ I become dehydrated.
 To delay cord clamping until the cord stops pulsating and
turns limp. The longer, the better.

Partner to cut the cord once it stops pulsating.

Placenta to be delivered naturally without physical

intervention/induction. To save placenta for burial later.

To provide immediate skin to skin and leave me and partner

alone in privacy for bonding.

To assist in latching baby for breastfeeding as soon as

possible.

To delay examinations of baby and allow husband to

accompany if absolutely urgent and necessary.

To not provide pacifier to baby.

To not provide formula milk to baby. I plan to exclusively

breastfeed baby.

To not bathe baby. Instead, gently wipe off blood and rub in
the vernix to be absorbed into baby’s skin.

Please sign our birth preference in good faith that it has been read, will be treated respectfully and that
we have your support in all of the above.

Signed: Date:

Name: