Birth Plan Template

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

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: