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Birth Plan Template

There are many birth options from vaginal to cesarean, locations vary from at home births to hospitals. The array of options provide expectant mothers with many choices that should be made prior to birth. Having a preexisting birth plan ensures the birth of your choice and support from your birth team. Below provides a detailed outline of a sample birth plan. Use this layout to customize your very own plan and inform your birth team of your desires. Share your birth plan with members of your birth team prior to birth in order to ensure every team member is prepared and willing to follow your blueprint. Prepare copies to all birth team members upon completion. Remember, it is your birth. There are no wrong or right ways, just the way your body and self are prepared for.

Before Labor

  • I prefer to have ___ vaginal exams
  • I prefer to have ___ ultrasounds
  • Discuss induction options prior to due date
  • I want at least ___ days post my due date before inducing labor, as long as baby and I are healthy
  • I want no time restrictions if I go past my due date, and plan to have no induction, as long as baby and I are healthy
  • I want to labor at home for as long as possible

Induction

For induction methods I do or do not want the following:

  • Acupuncture
  • Chiropractic
  • Enema
  • Herbs
  • Stripping membranes
  • Pitocin

I would like the following time period before induction

  • Wait 6 hours
  • Wait 12 hours
  • As long as baby and I are healthy, I want no induction methods

Environment

  • I prefer the following location for my birth:
    • Home
    • Birthing Center (Name and Address)
    • Hospital (Name and Address)
  • I want to utilize the following options during labor:
    • Water birth
    • Shower
    • Birthing bed
    • Birthing ball
    • Squatting
  • I want or do not want the following in the room:
    • Partner
    • Midwife
    • Doula
    • Chiropractor
    • Children
    • Parents
    • Extended family
    • I want privacy. Limit or restrict all visitors

Pain Relief

  • Only if I request, offer pain relief
  • Offer and suggest pain relief when needed
  • I want to discuss pain relief methods as soon as possible
  • Use the following methods to relieve pain:
    • Breathing techniques
    • Mediation
    • Acupuncture
    • Massage
    • Hypnosis
    • Water therapy
    • Walking and movement
    • Epidural
    • Narcotics

Labor

Time Limits:

  • I want zero time limits for laboring and pushing as long as I and baby are healthy
  • Medical intervention will be allowed after __ hours of pushing.

Positions:

I prefer the following positions during labor:

  • Standing
  • Squatting
  • On the toilet
  • Hands and knees
  • Medical ball
  • Lying down
  • Avoid stirrups

Episiotomy

  • I want no episiotomy and will risk tearing
  • I want an episiotomy

Monitoring

  • Continuous monitoring
  • Intermittent monitoring
  • Utilize the Lamaze, Bradley, and/or Childbirth Hypnosis techniques

Delivery

  • When pushing, I want to rely on instincts instead of orders from birth professionals.
  • When pushing, I want guidance on when or when not to push.
  • Please avoid the use of forceps and vacuum extractions.
  • Forceps and vacuum extractions may be used to assist delivery.
  • I would like my partner to catch the baby as he/she is delivered.
  • I would like my birth professional to catch the baby as he/she is delivered.
  • If an emergency cesarean is needed, please allow my partner and I time to discuss details and follow our initial newborn procedures below.

Cesarean

  • Unless a medical emergency, I opt not to have a cesarean.
  • Inform me on when it may be a good option to have a cesarean
  • I want to plan and schedule a cesarean.
  • I would like to hold my baby immediately after delivery
  • If I am unable to hold my baby, I want my partner to be able to have first contact.
  • I would like my baby to be sent to the nursery as I recover.

Newborn Procedures

  • I request immediate skin to skin contact as soon as baby is delivered
  • I request the time to breastfeed baby before we are separated
  • I opt of having my baby bathe right after birth
  • My partner and I will bathe our baby using our own bathing products
  • I do or do not want eye drops administered to my baby
  • I decline PKU testing
  • I would like to delay PKU testing
  • I want routine PKU testing
  • Do or do not administer Vitamin K
  • Postpone all immunizations
  • I would like all routine immunizations
  • Do not circumcise my baby
  • Do not retract baby’s foreskin
  • I would like my baby circumcised
  • I would like to meet with a lactation consultant as soon as possible
  • I want my baby to exclusively be breastfed
  • I want to combine breastfeeding and formula feeding
  • I want my baby to be formula fed
  • I would like all newborn procedures to be performed immediately
  • I want my baby in the room with me at all times, unless there is an emergency
  • I prefer my baby to partially stay in the nursery when I am resting
  • I would like the nursery to fully care for my baby and bring him/her for feedings

Third Stage Labor

Umbilical Cord:

  • Avoid clamping until pulsation stops
  • Allow partner to cut cord
  • Delay cord cutting for ____ time.
  • I made arrangements to bank baby’s cord

Placenta

  • Use Pitocin to promote placenta to be born
  • Avoid Pitocin unless there are risks of hemorrhage
  • I made arrangements to take the placenta home   

Hospital Stay  

  • Be as short as possible
  • Be as long as possible
  • I prefer a private room
  • I prefer my partner to remain in the room during my stay. Please provide accommodations
  • I prefer my family and children to be allowed with no restrictions
  • I prefer guests to be allowed to visit with no restrictions
  • I want privacy during my hospital stay. Limit or restrict all visitors
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