Fillable Printable One Page Birth Plan Template
Fillable Printable One Page Birth Plan Template
One Page Birth Plan Template
Mother’s name: __________________________________________________________________________________________________________
Partner’s name: __________________________________________________________________________________________________________
Additional labor companions:______________________________________________________________________________________________
Doctor or midwife: ______________________________________________________________________________________________________
What classes have you taken to prepare for the birth of your baby? ______________________________________________________________
(Preparing for Birth, Caring for Your Newborn, Breastfeeding Basics, etc.)
What would you like the environment in your labor room to be like?____________________________________________________________
(Calm, quiet, dark, brightly lit, noisy)
Who do you wish to be present during labor and at your baby’s birth? __________________________________________________________
How can the nurses best help you?__________________________________________________________________________________________
Should they stand in the background and let your partner help, offer suggestions, help with comfort measures?
Positions you think you’d prefer during labor ________________________________________________________________________________
(Walking, sitting on birth ball, rocking chair, swaying, waterbirth, etc.)
What concerns or frightens you most about your labor and birth? ______________________________________________________________
(Pain, medications, injections, etc.)
What relaxation techniques help you most? __________________________________________________________________________________
(Deep breathing, shower or bath, heat or cold therapy, music, massage, etc.)
What do you feel about pain medications during labor and birth? ______________________________________________________________
(Only if I ask, offer if I’m uncomfortable, offer after we’ve tried various other techniques, offer as soon as possible, etc.)
How do you feel about an episiotomy? ______________________________________________________________________________________
(Prefer no episiotomy and instead try compresses or massage, prefer an episiotomy if it’s needed)
Does your labor partner have any special requests? ____________________________________________________________________________
Who would you like to cut the umbilical cord? ___Partner ___Doctor or nurse
Does your labor partner have any fears or concerns? __________________________________________________________________________
How are you planning to feed your baby? ___Breast ___Bottle
If you have a boy, do you want him to be circumcised? ___Yes ___No (Check with insurance to determine coverage)
Would you or your partner like to be present at the circumcision? ___Yes ___No
Have you chosen a doctor or provider for your baby? __________________________________________________________________________
What kinds of questions do you have about infant care that we can answer while you are in the hospital?
________________________________________________________________________________________________________________________
Is there anything else you would like us to know about your preferences, concerns or wishes for your labor, birth and hospital stay?
________________________________________________________________________________________________________________________
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HealthEast
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maternity care
Birth Plan
A birth plan is a way of communicating your labor and birth preferences with your doctor or midwife and nurses in the hospital.
Simply put, a birth plan is a listing of the choices and preferences you and your partner have about labor, birth and your hospital stay.
Discuss your options with your partner and talk to your doctor or midwife about your choices.
Give a copy of your birth plan to your doctor or midwife and bring a copy to the hospital. The staff will work to follow your plan.
However, your safety and your baby’s safety is their priority. Depending on the course of your labor, some of your requests may
not be possible. It’s best to be flexible as you draft your birth plan and look on it as a list of preferences that may need to be
adjusted as labor progresses.
We have provided a sample birth plan below.
