Fillable Printable Sample Birth Plan Template
Fillable Printable Sample Birth Plan Template
Sample Birth Plan Template
Full name: Partner’s name:
Doctor’s name: Hospital name:
Please note that I:
Have group B strep
Am Rh incompatibility with baby
Have gestational diabetes
Page 1 of 6
Today’s date:
Due date/Induction date:
My delivery is planned as:
Vaginal
C-section
Water birth
VBAC
I’d like...
Partner:
Parents:
Other children:
Doula:
Other:
...present before AND/OR during labor
During labor I’d like...
Music played (I will provide)
The lights dimmed
The room as quiet as possible
As few interruptions as possible
As few vaginal exams as possible
Hospital staff limited to my own doctor
and nurses (no students, residents or
interns present)
To wear my own clothes
To wear my contact lens the entire time
My partner to film AND/OR take pictures
My partner to be present the entire time
To stay hydrated with clear liquids & ice chips
To eat and drink as approved by my doctor
Use this easy fill-in-the-blank birth plan to prepare yourself for delivery and communicate your wants and needs
to your medical team.
birth plan
I’d like to spend the first stage of labor:
Standing up
Lying down
Walking around
In the shower
In the bathub
I’m not interested in:
An enema
Shaving of my pubic area
A urinary catheter
An IV, unless I’m dehydrated (and a
heparin or saline lock IS/IS NOT okay)
I’d like fetal monitoring to be:
Continuous
Intermittent
Internal
External
Performed only by Doppler
Performed only if the baby is in distress
I’d like labor augmentation:
Performed only if baby is in distress
First attempted by natural methods such
as nipple stimulation
Performed by membrane stripping
Performed with prostaglandin gel
Performed with Pitocin
Performed by rupture of the membrane
Performed by stripping of the membrane
Never to include an artificial rupture of
the membrane
For pain relief I’d like to use:
Acupressure
Acupuncture
Breathing techniques
Cold therapy
Demerol
Distraction
Hot therapy
Hypnosis
Massage
Meditation
Reflexology
Standard epidural
TENS
Walking epidural
Nothing
Only what I request at the time
Whatever is suggested at the time
Page 2 of 6
birth plan
I will bring a:
Birthing stool
Birthing chair
Squattng bar
Birthing tub
During delivery I would like to:
Squat
Semi-recline
Lie on my side
Be on my hands and knees
Stand
Lean on my partner
Use people for leg support
Use foot pedals for support
Use birth bar for support
Use a birthing stool
Be in a birthing tub
Be in the shower
I would like an episiotomy:
Used only after perineal massage, warm
compresses and positioning
Rather than risk a tear
Not performed, even if it means risking
a tear
Performed only as a last resort
Performed as my doctor deems necessary
Performed with local anesthesia
Performed by pressure, without local anesthesia
Followed by local anesthesia for the repair
As the baby is delivered, I would like to:
Push spontaneously
Push as directed
Push without time limits, as long as the
baby and I are not at risk
Use a mirror to see the baby crown
Touch the head as it crowns
Let the epidural wear off while pushing
Have a full dose of epidural
Avoid forceps usage
Avoid vacuum extraction
Use whatever methods my doctor
deems necessary
Help catch the baby
Let my partner catch the baby
Let my partner suction the baby
Page 3 of 6
birth plan
I would like to hold baby:
Immediately after delivery
After suctioning
After weighing
After being wiped clean and swaddled
Before eye drops/ointment are given
I would like to breastfeed:
As soon as possible after delivery
Before eye drops/ointment are given
Later
Never
Immediately after delivery, I would like:
My partner to cut the umbilical cord
The umbilical cord to be cut only after it
stops pulsating
To bank the cord blood
To donate the cord blood
To deliver the placenta spontaneously and
without assistance
To see the placenta before it is discarded
Not to be given Pitocin/oxytocin
I would like my family members:
(names:)
To join me and baby immediately after
delivery
To join me and baby in the room later
Only to see baby in the nursery
To have unlimited visiting after birth
If a C-section is necessary, I would like:
A second opinion
To make sure all other options have been
exhausted
To stay conscious
My partner to remain with me the entire
time
The screen lowered so I can watch baby
come out
My hands left free so I can touch the baby
The surgery explained as it happens
An epidural for anesthesia
My partner to hold the baby as soon as possible
To breastfeed in the recovery room
Page 4 of 6
birth plan
If we have a boy, a circumcision should:
Be performed
Not be performed
Be performed later
Be performed with anesthesia
Be performed in the presence of me
AND/OR my partner
I would like baby’s medical exam & procedures:
Given in my presence
Given only after we’ve bonded
Given in my partner’s presence
To include a heel stick for screening tests
beyond the PKU
To include a hearing screening test
To include a hepatitis B vaccine
Please don’t give baby:
Vitamin K
Antibiotic eye treatment
Sugar water
Formula
A pacifier
I’d like baby to stay in my room:
All the time
During the day
Only when I’m awake
Only for feeding
Only when I request
I’d like my partner:
To have unlimited visiting
To sleep in my room
I’d like baby’s first bath given:
In my presence
In my partner’s presence
By me
By my partner
I’d like to feed baby:
Only with breastmilk
Only with formula
On demand
On schedule
With the help of a lactation specialist
Page 5 of 6
birth plan
As needed post-delivery, please give me:
Extra-strength acetaminophen
Percoset
Stool softener
Laxative
After birth, I’d like to stay in the hospital:
As long as possible
As briefly as possible
If baby is not well, I’d like:
My partner and I to accompany it to the
NICU or another facility
To breastfeed or provide pumped
breastmilk
To hold him or her whenever possible
Page 6 of 6
birth plan
