Birth Plan Template: Labor, Pain Relief and Newborn Care

Birth Plan Template

This Birth Plan (“Plan”) is prepared by:

Parent’s Name: [Your Full Name]

Expected Due Date: [Date]

Hospital or Birthing Center: [Facility Name]

Care Provider: [Doctor / Midwife Name]

Support Person(s): [Partner, Doula, Family Member]

This Plan outlines my preferences for labor, delivery, and immediate postpartum care. I understand that flexibility may be required based on medical circumstances.

1. Labor Preferences

• I would like to:

  ☐ Walk and move freely during labor

  ☐ Use a birthing ball / shower / tub

  ☐ Have a quiet, dimly lit environment

  ☐ Limit vaginal exams

  ☐ Use music or calming sounds

  ☐ Eat or drink during labor (if allowed)

• Preferred positions for labor:

  ☐ Upright ☐ Squatting ☐ Hands and knees ☐ Side-lying ☐ No preference

I would like to:

☐ Walk and move freely during labor

☐ Use a birthing ball / shower / tub

☐ Have a quiet, dimly lit environment

☐ Limit vaginal exams

☐ Use music or calming sounds

☐ Eat or drink during labor (if allowed)

Preferred positions for labor:

☐ Upright ☐ Squatting ☐ Hands and knees ☐ Side-lying ☐ No preference

2. Pain Management

I prefer:

☐ Unmedicated birth

☐ Open to pain relief if needed

☐ Epidural

☐ IV pain medication

☐ Non-medical methods (breathing, massage, etc.)

3. Monitoring Preferences

☐ Intermittent monitoring

☐ Continuous electronic fetal monitoring

☐ Only as medically necessary

4. Interventions

I would like to avoid (unless medically necessary):

☐ Pitocin (labor induction/augmentation)

☐ Artificial rupture of membranes

☐ Episiotomy

☐ Forceps or vacuum extraction

☐ C-section (unless emergency)

5. Support During Labor

I would like the following people present:

[Names of people allowed in delivery room]

☐ I would like my partner/support person to cut the umbilical cord

☐ I prefer minimal staff changes during labor

6. Delivery Preferences

• I would like to:

  ☐ Use a mirror to see the birth

  ☐ Touch my baby’s head as it crowns

  ☐ Push spontaneously

  ☐ Be coached while pushing

  ☐ Deliver in alternative positions (e.g., squatting, side-lying)

7. After Birth

• I would like:

  ☐ Immediate skin-to-skin contact

  ☐ Delayed cord clamping

  ☐ Partner to hold baby first

  ☐ Baby placed on my chest for first examination

  ☐ Breastfeeding within the first hour

  ☐ To delay newborn procedures if baby is stable

8. Baby Care

☐ Breastfeeding only

☐ Combination feeding

☐ Formula feeding

☐ Vitamin K: Injection / Oral / Decline

☐ Eye ointment: Accept / Decline

☐ Hepatitis B vaccine: Accept / Delay / Decline

9. Unexpected Situations

If a C-section is required, I would prefer:

☐ Partner present

☐ Skin-to-skin in the OR (if possible)

☐ Breastfeeding as soon as possible

☐ Clear drape to view birth (optional)

10. Additional Notes

[Here you can write any personal requests, spiritual/cultural considerations, or special instructions.]

Acknowledgment

I understand that while every effort will be made to follow this Plan, medical needs and circumstances may require adjustments. I trust my care team to act in the best interest of myself and my baby.

Signature

Name:

Date: