Birth plan template

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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

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. 

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

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

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

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

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