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Name of Mother............................................................................................... Previous Birthing Experience............................................................................. Statement of General Birthing Philosophy and Intention......................................
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....................................................................................................................... Primary Medical Care Givers............................................................................ Other Supporters / Assistants............................................................................ Other People.................................................................................................... Active Birthing.................................................................................................. Environment...................................................................................................... Food ............................................................................................................... Monitoring and Examination ............................................................................. Labour Induction and Progress of 1st Stage ...................................................... Membrane Rupture .......................................................................................... Management of Pain......................................................................................... 2nd Stage Management .................................................................................... Sex Identification ............................................................................................. Placental Delivery ............................................................................................ Cutting of the Cord .......................................................................................... First Contact .................................................................................................... First Feed................ ........................................................................................ In Case of Separation ...................................................................................... In Case of Caesarean ....................................................................................... Post-Partum Baby Care ................................................................................... Departure Timeframe ....................................................................................... Anything Else ..................................................................................................
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