Birth Plan Template

A Birth Plan should be a thoughtful reflection of your values.  It can be a useful communication tool between you and your caregiver. Ideally, this communication starts early in pregnancy. The following is a sample introduction and a list of suggested topics you might want to address in your birth plan. Keep your birth plan simple and no more than one page long. Address only the things that are important to you: 

Best Case Birth Scenario 

We (I) have chosen Dr. ______________  and _______________ Hospital because of their excellent reputation in supporting women through the process of childbirth. We (I) understand that birth doesn’t always go “as planned”, and that’s why we have you on our team, however, barring any situations in which mother’s or baby’s safety is in jeopardy, the following “wish list” represents our best case birth scenario. It is intended not as a list of “demands” but as a tool to facilitate communication between us. We (I) ask that we (I) be included in the decision making process during our (my) birth, and together, we can make this a positive and joyous occasion.

Support 

Presence of coach and/or doula during labor, delivery, etc.

Presence of interns, residents, other personnel

Labor 

Continuous presence of father, doula, mother, etc.

Mobility

Fluids and food

Ambience of environment (i.e. quiet, dim lights, music, interruptions, etc.)

Medical interventions:

IV (this is usually required if dehydrated, GBS+, desire epidural, or need pitocin)

Amniotomy (breaking bag of water)

Monitoring (continuous or intermittent, external or internal?)

Vaginal exams (important to limit if bag of water is broken; also consider the psychological effect of learning you’ve not made as much progress as you thought)

Pitocin

Pain medication/epidural

Delivery 

When to start pushing (waiting for urge to push, station of baby, etc)

Birthing positions (squatting, hands and knees, side-lying, etc)

Breathing during pushing stage

Support and encouragement

People in room, ambience

Mirror to see baby emerge

Episiotomy

Perineal massage, warm compresses

Baby delivered to abdomen

Dad or Mom deliver baby?

Who cuts cord and when (allow to continue pulsating?)

Placenta (keep or see?)

Donate or bank umbilical cord blood

In the event of cesarean delivery:

Desire to be fully informed of all interventions

Coach and/or doula present for birth

Type of anesthesia (epidural or spinal)

Lowering of screen prior to delivery

Holding baby after delivery (by coach and/or mother)

Sedatives after see baby? (sedatives are associated with maternal amnesia)

Baby brought to recovery room for feeding

Immediately After Delivery 

Hold the baby until…..

If baby must be taken away from mother for any reason, father accompanies

Skin to skin

Initiation of breastfeeding

Baby’s medications (Vitamin K, Erythromycin eye ointment, Hepatitis B)

Postpartum Period

Rooming In

Breastfeeding, bottles, glucose water, pacifiers

Circumcision—yes or no (if yes, request anesthesia?)

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