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Birth Plan

This is a complete birth plan – from epidurals to skin-to-skin contact to cord blood banking.

Make sure you are familiar with ALL your options before your labor & delivery.

Birth Plan Template – Printable

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Birth Plan Template

Here are the contents of your birth plan.

To fill it it for yourself & print, just enter your email above & I’ll send it to you!

Birth Plan for:
My birth partners are:
Allergies:
Blood Type:
Rh Factor:
Health Care Provider Name:

Environment
I would like to bring music.
I would prefer dim lighting.
I would prefer silence.
I would like to wear my own clothes.
I would prefer to stay in one room during labor, birth, and post delivery if possible.
I would like to be able to film baby’s birth.
I would prefer no students to be present.
I would like to be able to walk around, mobility is important to me.
I would prefer a warm bath over walking. Please let me try that if I do not feel up to walking.

Equipment
I would like the following equipment available to me. If unavailable, I would like to bring them with me: birthing bed, birthing ball, birthing stool, beanbag, birthing pool, tub, or shower.

Preparation
I would prefer to be given an enema.
I would prefer not to be given an enema.
I would like to wear contact lenses if possible.
I would prefer to be able to eat and drink during labor.
I would prefer no IV unless absolutely necessary.
If I need an IV, I would like to use a heparin or saline lock.

Monitoring
I would prefer no monitoring to be done if there are no signs of distress.
I would prefer external monitoring if monitoring is necessary.
I am comfortable using an internal monitor.

Anesthesia – Pain medication
I would prefer to try laboring without pain medication. I know what’s available & will ask if I need it.
I would like to try narcotic medications before being offered an epidural.
I would like an epidural.
I would like a walking epidural.

First Stage of Labor
I do not want to be separated from my partner during labor or birth.
I would like the option of returning home if my labor is not progressing.
I would like no time limits on laboring and prefer labor not to be augmented unless medically necessary.
I would prefer my water not be broken.
No internal examinations, please, unless there is actual concern about the baby’s wellbeing.
If you need to do a vaginal exam, please do not tell me how dilated I am.
I would like encouragement throughout labor.
If you need to ask questions, please refer to my partner who knows my wishes.

Episiotomy
I’d prefer not to have an episiotomy.
I’d prefer to have an episiotomy.

Second Stage of Labor (pushing)
I’d like a mirror present to view birth.
I’d like to be able to touch baby as it crowns.
I’d like my legs supported when I push.
I’d like to be able to try any position comfortable during pushing.
I would like counting to help me push.
I would like to wait to push until I feel the urge even if I am fully dilated.
No time limits on pushing unless medically necessary. No directed pushing.

After Birth
I’d like my partner to catch the baby.
I’d like to have skin-to-skin immediately.
I’d like to cut the cord myself.
I’d like to have my partner cut the cord.
My partner does not wish to cut the cord. Please do not ask.
I’d like to wait on cutting the umbilical cord until it stops pulsating.
Don’t be in a hurry to clamp and cut the cord or to deliver the placenta (natural Third Stage unless indicated otherwise).
I would like to see my placenta after birth.
I have made arrangements to keep my placenta after birth.
I do not wish to see my placenta after birth.
I would like baby to room in with me.
I would like baby to stay in nursery at night so I can rest.
I would like my partner to stay in the room.
I would like to bank baby’s umbilical cord blood.
I would like to donate my baby’s umbilical cord blood.
I’d like to be discharged as soon as possible.
I’d like to stay as long as possible.
I’d like to have baby’s first bath and assessment to be done in my presence.
Baby to be given Vitamin K orally/by injection/not at all

Bottles & Pacifiers
I would prefer to bottlefeed.
I do not want my baby to have a bottle. I would prefer cup feeding or finger feeding if supplements are necessary.
I do not want my baby given formula or water.
I do not want my baby to have a pacifier.
I would like my baby to have a pacifier. I am aware of the risks for nipple confusion.
I would like to see a lactation consultant.
I would like any gift bags or diaper bags given to have formula removed.

Cesarian Section
I would like to avoid a c-section if possible.
I would like my partner present.
I would like skin-to-skin with baby immediately.
I would like partner to hold baby after birth.
I would like screen lowered so I can view birth.
I would like to film c-section.
I would like to breastfeed baby as soon as possible.

Breastfeeding
I would prefer to breastfeed.
I would like to breastfeed and bottlefeed.
I would like to see a lactation consultant.
I would like any gift bags or diaper bags given to have formula removed.
I would like ________________________________ to help me with breastfeeding.
Please let the baby take his/her own time to feed, & respect our need for time together without stress or pressure.
In case of baby’s removal to NICU, no formula supplements to be given to the baby without my express consent.