Fillable Printable Blank Birth Plan Template

Blank Birth Plan Template

!!! !

We!are!excited!to!share!in!the!birth!of!your!baby!!Our!goal!is!for!you!to!have!the!safest!and!

most!rewarding!experience!possible.!As!you!make!decisions!regarding!your!birth!experience!

we!encourage!you!to!discuss!them!with!your!physician!or!Midwife.!Completing!this!Birth!Plan!

will!help!us!get!to!know!you!and!tailor!our!care!for!you!and!your!family.!!

Please!remember!that!as!your!health!care!needs!change,!so!may!your!birth!plan.!!

We!are!committed!to!help!you!achieve!the!birth!experience!you!and!your!family!desire.!

My!Name:!_________________________Due!Date:!________________!

Lab or!Compani ons:!__________________________________________!

Healthcar e!Provider:!__________________________________________!

During Labor I Prefer…

Dimmed Lighting

Music played (I will provide)

To bring items in from home like blankets, aromatherapy scents, massage oil.

The room as quiet as possible

To wear my own clothing

To walk during early labor and try multiple positions during labor

I understand that if I get an epidural I will be confined to bed

I would like to stay hydrated with clear liquids whenever possible during labor

A saline lock if the placement of an IV is needed for hydration during labor.

To be intermittently monitored in early labor so I can walk and move freely.

To walk while being monitored by telemetry.

For Pain Relief…

Nonmedical Options:

I’d like to use relaxation techniques such as:

Various labor positions

Visualization Massage

Birthing Ball Breathing Techniques

Tub/Shower

Hot/cold packs

Medical Options:

Analgesics (Narcotics) Epidural

Congra tulations,on,Choosi ng,Sarasota,Memorial!,

If!Augmentation!is!N eeded…!

If my labor slows down, I would:

First like to try nonmedical methods like walking and using upright forward leaning labor

positions.

Prefer that my practitioner breaks my bag of waters.

Prefer that my bag of waters breaks on its own.

Prefer to receive an IV of Pitocin only after all other methods are tried, and only if medically

necessary.

During!P ushing!I!would!like …!

To wait to push until I feel the urge or until my baby descends.

To use a variety of positions during pushing.

A mirror placed at the foot of the bed so I can watch my baby’s birth.

I would like to be directed as to when to push.

I prefer any natural tearing over an episiotomy.

I would like to avoid forceps and/or vacuum extraction unless absolutely necessary.

I would like to touch my baby’s head as it crowns.

Birth!and!Baby!Care!

I would like __________________ to cut the umbilical the cord on the warmer.

I am interested in delayed cord clamping.

I would like to bank my baby’s umbilical cord blood and have talked with my caregiver

regarding process.

I would prefer that routine hospital procedures be done while I hold my baby if possible.

I would like all routine shots and drops for my newborn delayed if possible.

I am breastfeeding exclusively.

I plan to formula feed only.

In!Ca se!of! a!Ces arean!Birt h…!

If possible, I would like _________ to accompany me into the OR. (add name )

If anesthesia is a choice for me, I would prefer an epidural.

If anesthesia is a choice for me, I would prefer a spinal.

I would like the sterile blue drape lowered for the birth.

I would like my support person to cut the cord on the warmer.

I would like to have at least one arm released so I can hold my baby right away if

permitted and the baby’s medical condition is stable.

I would like to breastfeed as soon as possible in the recovery room.