Sample Birth Plan

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

While you may want to create a shorter version of your birth plan that takes into account all of the amenities and rules at the hospital/birth center you prefer to deliver in, we suggest you keep a comprehensive version in your purse, husband’s wallet and car for use in case of unexpected circumstances.

For example, while our of town traveling you go into labor early. In this situation or for whatever reason you cannot deliver in your planned location with your planned doctor/midwife, a comprehensive birth plan is your best way of quickly communicating your wishes so you can still have the best possible birth experience.

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Another reason that we have created a comprehensive sample birth plan template is to give you and your husband/partner a format for reviewing, discussing and agreeing on your birth options. Statistics show that women that surround themselves with people that are advocating for a natural childbirth are most likely to have one.

Learn more about how natural childbirth can protect you from a cascade of medical interventions and protects you and your baby.

Ensuring that you and your husband/partner are in alignment is critical since you will be focusing on what your body is doing during labor and you need your husband to be your advocate to ensure your wishes are considered.

You will also want to review your birth plan with your birth attendants (doctor(s), midwife, doula) to get their agreement. Plan to give everyone a copy of your birth plan for their files at least 4 weeks before your due date. Often, obstetrician practices will send your file over to labor and delivery 3 or 4 weeks before your due date. You want your birth plan to be in your file before they send it over.

This sample birth plan can be copied and pasted into Microsoft Word or another editor to make changes. Just change the title "sample birth plan" to (insert your name) Birth Plan

Above all…enjoy planning your birth! This is an exciting time.

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Sample Birth Plan

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

Date Created: Enter Date

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

Birth Facility: Hospital or Birthing Center Name

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’s name] discuss with us any procedures or medications before administering them, whenever possible. We greatly appreciate your cooperation in realizing our plan.

Environment

Here is where you indicate what kind of environment you would like for your birth. Feel free to make any modifications you desire to this sample birth plan

• 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), squatting bar
• I would like to bring the following birthing equipment with me: (List everything you plan to bring
• Birthing stool
• Birth ball
• Birth tub

Prior to Labor

Following the natural process, it is believed that your baby will trigger labor when he/she is ready to be born. Here is where you indicate that you want to go into labor naturally as well as how you plan to handle the early signs of labor , and when you plan to transfer to the hospital. Feel free to make any modifications you desire to this sample birth plan

• If I go past my estimated due date, I would prefer not to induce labor as long as my 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

First-Stage Labor

Here is where you indicate how you plan to handle the early stage of labor as well as active labor . Feel free to make any modifications you desire to this sample birth plan

• If I go past my estimated due date, I would prefer not to induce labor as long as my 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: (list all that you plan to use)
• 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 my baby and I are fine, I would like to be free of time limits and not have my labor augmented.

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 sample birth plan

• 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 Section

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 sample birth plan.

• 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 sample birth plan.

• 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.
• NO BOTTLES, NO PACIFIERS!! We suggest emphasizing this since it is often overlooked, especially if your baby is out of your sight.

Newborn Procedures

This section is for you to express your wishes with regard to newborn procedures. This is the first time you will be making decisions on behalf of your baby. This section is often overlooked, but important since it is usually the pediatrician on call, NOT your obstetrician or midwife who will be performing the newborn procedures. Check with you medical attendant ahead of time to find out about the policies for your planned birth location and try to have any waivers necessary signed ahead of time to simplify the process and ensure your wishes are followed. Again, it is best to keep your baby in your sight to prevent mistakes if you are not following all of the routine hospital protocols. Feel free to make any modifications you desire to this sample birth plan.

• 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!!

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For More Information

To get the most out of this sample birth plan, you may want to refer to the following links for more information so you understand the different options available to you.

• Women Giving Birth in the Hospital - Important Information for a Hospital Birth
• Stages of Labor and Delivery - What to do in Each Stage
• Early Signs of Labor - How to Recognize Them
• Active Labor - What it Feels Like and What to Do
• Transition - The Shortest and Most Intense Stage
• Pushing Stage - Effective Pushing Techniques
• Delivery of the Placenta - Important yet often Overlooked

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