Your Birth Plan Template – The Birthing Lady

Your Name *

First

Last

Email *

Phone Number

City you reside *

Helps us determine location for support

Estimated Due Date

Where do you plan to give birth?

Hospital
Birthing Center
Home
Other

Name & Address of Birth Place

Doctor/Care Provider's Name *

First

Last

Support Person(s)

Share who you would like to be present at your birth

Name of Support Person(s) *

First

Last

Name of Support Person(s) *

First

Last

Other Support Person Info

Background Information

Share how you see your labor progressing. Do you want to labor at home? Do you need support at home during the earlier times of labor?

List any food and/or medication allergies

Do you have any health concerns that could affect your birth wishes?

Please share any physical, mental, or emotional concerns. Birth can be a vulnerable time and understanding some of these concerns can create a safe and supportive space for the birth of your baby

Environment

Optional thoughts

Pain Management & Strategy

I would like to be offered pain medication when I appear to be in pain
Please do not offer me pain medication unless I specifically request it
I plan to use alternative measures for pain control (birth ball, tub, etc)
I hired a Doula to help me manage the discomfort naturally
I plan to use a specific birth training program (Hypnobirthing, Hypnobabies, Bradley, etc)
I am unsure if I want pain medication and would like my options explained to me

Please check the box(s) that closely shares how you’d prefer to manage the discomfort of labor.

Other thoughts on pain management

First Stage or Labor

I’d prefer my water break on it’s own
I’d like music playing, that I plan to provide
I’d like to move around
I’d like coaching on when and how to push
I would like to wear my own clothes
I would like to choose the position I deliver in

I'd prefer fetal monitoring to be

Second Stage of Labor

Support people in the room continuously
To allow labor to take its natural course, with few interruptions
To keep me comfortable with pain medicine
Episiotomy only if necessary and after consult
I’d like to touch my babies head as it crowns
I’d like my partner to catch my baby
I’d like the lights dimmed during delivery
I’d like skin-to-skin with the baby immediately after the birth

If I'm having a C-Section, I would like:

**A gentle C-section is sometimes referred to as a family centered Cesarean. Baby is birthed slower than a conventional C-section. This is an option that creates a more natural feel for the baby upon entering the world.

After Birth

Delayed cord clamping and cutting until after pulsation has ceased
Skin-to-skin contact immediately after the birth
I’d like a warm blanket to keep me comfortable
I would like to be asked before a pacifier or formula is given to my baby
I would like the option of taking home the placenta

I'd like _________________ to cut the umbilical cord

I'd like to delay my baby's first bath:

1 hour after the birth
The next day
Do not delay
I do not want a bath at all

Postpartum

I would like to delay all procedures until after an hour of skin-to-skin contact so I can feed and bond with my baby
If my baby needs medical care requiring separation from me, I would like my partner to accompany my baby
All newborn procedures can be performed after the birth
I’d like more info on my choices for the newborn procedures (eye ointment, Vit K, vaccines, circumcision, PKU, etc)

I plan to:

Exclusively breastfeed
Combination feed
Exclusively formula feed while in the hospital

I'd like my baby to:

Stay in the room with me
Stay in the nursery
All procedures, medications and exams should be explained to me before done
I’d like to meet with a lactation specialist

Share any past birth experiences that you would like to avoid

Share some short wishes for you nurses

Example-We wish to thank everyone in advance for their assistance during this special experience for our family.

What wishes are a MUST and critical to your birth plan?