Birth Plan Template

Feel free to use our birth plan template to create your own. This template contains most of the natural childbirth options you will want to consider for your own birth.

(Insert Your Name) Birth Plan

Date Created: Enter Date

Birth Attendant(s): Add Dr and/or Midwife name(s)

Birth Facility: Hospital or Birthing Center Name

Here is where you summarize the type of birth you desire. Feel free to make any modifications you desire to this birth plan template

It is our desire to have a natural, medication and intervention-free childbirth. We have educated ourselves and are prepared for the work involved. We understand that complications do arise and in such instances ask that [physician/midwife] discuss with us any procedures or medications before administering them, whenever possible. We greatly appreciate your cooperation in realizing our plan.

ENVIRONMENT

Feel free to make any modifications you desire to this birth plan template

  • I would like the following people to be present at the birth:
    • Husband: Enter Name
    • Labor Support: Enter Name
  • I would like to bring music
  • I would like the lights dimmed
  • I would like to wear my own clothes during labor and delivery
  • We would like to film and/or photograph in the delivery room
  • If available, I am interested in using the following amenities: Stereo, Birth Ball, Birth Stool, hot water for shower, Birthing Tub (inflatable)
  • I would like to bring the following birthing equipment with me:
    • Birthing stool
    • Birth ball

PRIOR TO LABOR

Remember to make any modifications you desire to this birth plan template

  • If I go past my estimated due date, I would prefer not to induce labor as long as the baby and I are fine
  • If water breaks at onset of labor, I would like to wait 24-48 hours or more before inducing, me and my baby's condition permitting
  • I would like the option to return home if I'm less than four centimeters dilated
Birth Plan

FIRST-STAGE LABOR

Feel free to make any modifications you desire to this birth plan template

  • If I go past my estimated due date, I would prefer not to induce labor as long as the baby and I are fine.
  • If water breaks at onset of labor, I would like to wait 24-48 hours or more before inducing, me and my baby's condition permitting.
  • I would like the option to return home if I'm less than four centimeters dilated.
  • I do not want pain medication offered to me. I'll request it if needed.
  • I would like to be free to walk and move around as I choose during labor.
  • I would prefer not to be separated from my partner at any point during labor or birth.
  • I prefer not to have continuous monitoring other than the minimum necessary upon arrival.
  • I would like the baby to be monitored intermittently using a Doppler.
  • If I am required to have an IV, I would like to use a heparin or saline lock.
  • I would prefer not to undergo internal exams unless they are medically necessary.
  • I do not want my membranes stripped or water broken at any time.
  • I would like to eat and drink during labor.
  • I would like to stay hydrated by drinking clear fluids and using ice chips.
  • I would like to handle pain in the following ways:
    • Acupressure (my labor support person is certified in acupressure)
    • Acupuncture
    • Massage
    • Hypnosis
    • Relaxation
    • Bath/shower (I would like my husband to have the option to join me)
    • Position Changes
    • Walking
  • As long as the baby and I are fine, I would like to be free of time limits and not have my labor augmented.
Site Build It!

SECOND-STAGE LABOR

This section is where you express your wishes for the pushing stage . Feel free to make any modifications you desire to this birth plan template

  • I do not want residents or students to be present during my birth.
  • I would like to push instinctively and not be told how or when to push.
  • As long as the baby and I are fine, I would like to be free of time limits on pushing.
  • As long as the baby and I are fine, I would like to be free to push in the positions of my choosing.
  • I would rather risk a tear than have an episiotomy.
  • I would like to view the birth using a mirror.
  • I would like to touch my baby's head as it crowns and to be told when crowning is occurring so that I can slow down my pushing and deliver the head slowly provided all is well with the baby.
  • I would like my husband to catch my baby and place her on my chest immediately after birth.
  • I would like to be able to pull my baby out and hold her on my chest immediately after the birth.

CESAREAN SECTIONS

This section allows you to express your wishes if you end up having an emergency cesarean section. If you already have had a cesarean, you may want to state that you intend to do everything possible to prevent a repeat cesarean. Remember to make any modifications you desire to this birth plan template

  • I would like my partner to be present at all times during the operation.
  • I would like to be conscious.
  • I would like the screen lowered so I can see my baby coming out.
  • I would like to have one hand free to touch my baby.
  • We would like to videotape and/or photograph the operation and baby coming out.
  • I would like to have immediate contact with my baby (if my baby is in good health).
  • If I can't be with my baby for newborn procedures, my husband will stay with the baby at all times.

THIRD-STAGE LABOR

This section is for you to express your wishes immediately following the birth and for the delivery of the placenta . Feel free to make any modifications you desire to this birth plan template

  • I would like to hold my baby on my chest, skin to skin, immediately after birth.
  • I would like to wait until the umbilical cord stops pulsating before it's clamped and cut.
  • My husband would like to cut the umbilical cord.
  • I would like to deliver the placenta unassisted.
  • I prefer not to have routine Pitocin after the birth.
  • I would like to breastfeed my baby immediately following the birth.
  • I would prefer that no artificial nipples (bottles, pacifiers) be offered to my baby at any point.
  • I would like to feed my baby on demand.
  • I would like 24-hour rooming-in with my baby.
  • I would like to stay in a private room.
  • I would like my partner to spend the night with me.
  • I would like my hospital stay to be as short as possible.

NEWBORN PROCEDURES

This section is for you to express your wishes with regard to newborn tests and procedures . This is the first time you will be making decisions on behalf of your baby. Feel free to make any modifications you desire to this birth plan template

  • I would like to postpone newborn procedures until I have had a chance to bond with my baby. (45 minutes of skin to skin contact on my chest and breast feeding)
  • I would like all newborn procedures to take place in our presence.
  • Either my husband or I will stay with our baby at all times.
  • I do not want antibiotics to be put into my baby’s eyes and am prepared to sign a waiver if necessary. (I do not have venereal disease, so there is no need.)
  • I prefer that my baby does not receive a bath.
  • I would like Oral Vitamin K given to my baby not injection if Oral Vit K is not available then we prefer no Vitamin K and we are willing to sign a waiver if necessary.
  • I do not want any vaccinations administered to my baby.
  • NO BOTTLES, NO PACIFIERS!!

For More Information

Natural Childbirth Tips
Women giving birth in the hospital
Stages of labor and delivery
Early signs of labor
Early stage of labor
Active labor
Transition
Pushing stage
Delivery of the placenta


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