Birth plan template



Save, fill-In The Blanks, Print, Done!

Click on image to zoom / Click button below to see more images
Microsoft Word (.docx)

Or select the format you want and we convert it for you for free:



  • This Document Has Been Certified by a Professional
  • 100% customizable
  • This is a digital download (64.84 kB)
  • Language: English
  • We recommend downloading this file onto your computer.


  
ABT template rating: 7

Malware- and virusfree. Scanned by: Norton safe website

How to create a birth plan prior to going into labor?

In order to make my wishes clear to my doctor/midwife, and the nurses at the hospital where I am delivering. These are the items I deem important in the birth of my unborn baby and I would like them to be followed as closely as possible whenever able. I understand that a circumstance might come up where either I may change my mind or my doctor/midwife feels that it is in my best interest to deviate from my birth plan. I will be flexible; however, I ask to be kept informed ahead of time of every aspect of my labor.

My name: {{Name}}
My due date: {{Date}}
My provider's name: {{Name}}
Provider's number: {{Number}}
My partner's name: {{Name}} 
Refer to my baby as: {{Name}} (baby's name, son, daughter, your baby)

Pain Medication
When it comes to pain medication I request (check all that apply):
  • Shots through the IV of medication such as Demerol or Stanol
  • An epidural as soon as possible
  • Do not offer pain medication, let me ask for it if I need it
  • No medication at all, I want a drug free birth

Episiotomies and Tearing
When it comes to delivery I prefer (check all that apply):
  • An episiotomy
  • To tear naturally
  • An episiotomy ONLY if necessary
  • Perineal massage
  • Pain medication for stitching up a tear or cut

Visitors
When it comes to visitors during labor and deliver, I prefer (check all that apply):
  • Please allow all visitors to come and go as they please
  • I only want visitors during the early stages of labor
  • No visitors except for my birth partner
  • Do not allow these people

Immediately After Delivery
Immediately after I deliver, I prefer (check all that apply):
  • Please lay my baby on my chest immediately
  • Please clean up my baby before bringing him/her to me
  • We are donating/banking the cord blood
  • Please allow the cord to stop pulsating before cutting cord
  • Please allow my partner to cut the cord
  • Please allow my partner to stay with the baby
  • Please allow me to breastfeed immediately before you take baby to be cleaned, get eye drops etc. 

C-Section
In case a c-section is necessary, I prefer the following (check all that apply):
  • Allow my partner to accompany the baby to the nursery and stay with the baby at all times while I    am being stitched up
  • Bring my baby to my recovery room as soon as possible so I may bond and attempt nurse/feed
  • Wait till I get situated in my room before you bring me, my baby
  • Do not give my baby sugar water or formula in the nursery whether it is through a dropper or bottle
  • Go ahead and feed my baby in the nursery

Postpartum Care
For my postpartum care, I prefer (check all that apply):
  • I want my baby to room in at all times
  • I would like my baby to go to the nursery at my request
  • Please administer all tests and medications to my baby in my room
  • Allow my partner to have access to the nursery and to be with the baby at all times when the baby is removed from my presence
  • I want my birth partner to be allowed to stay the night
  • I want family and friends, including other children to have free reign when it comes to visitation

Feeding
When it comes to feeding my baby, I prefer (check all that apply):
  • I will be breastfeeding only
  • I will be breastfeeding and supplementing with formula
  • I will be formula feeding only
  • If in the nursery, bring my baby to me to feed on demand
  • Please feed my baby while in the nursery
  • Do not give my baby sugar water or formula in any situation whether via bottle, dropper or other method

Miscellaneous
Other things that are important to me include (check all that apply):
  • I want to take pictures during labor/birth
  • I want to take video during labor/birth
  • I prefer to be able to eat/drink during labor
  • I want to have the freedom to move around until/unless I request pain medicine
  • I want to be able to take a bath or shower to relieve pain during labor




DISCLAIMER
Nothing on this site shall be considered legal advice and no attorney-client relationship is established.


Leave a Reply. If you have any questions or remarks, feel free to post them below.


default user img

To win without risk is to triumph without glory. | Pierre Corneille