a sample birth plan

A Sample Birth Plan

I vividly remember someone asking me if I had a birth plan when I was pregnant with my first baby and immediately googling what this was exactly. I had no idea this was a thing. I mean how would I know? You don’t know until someone tells you. This blog is me passing along information that I did not once know, but now believe helped me achieve my birth goals. Feel free to modify and make this sample plan your own. Wishing you a beautiful birth and a peaceful postpartum.

Sample Birth Plan

Name:
Care Provider:
Pediatrician:
Birthing Team:

  • Partner:
  • Doula:
  • Midwife/OB:
  • Other:

To all present at the birth of our baby, we are so grateful. Without you, we know these preferences would not be possible. We appreciate your advocacy and commitment in providing the most natural delivery possible for the mother and baby.

ENVIRONMENT

Requested room with birthing tub, if available. Please help us keep the room restful by:

  • Closing the door
  • Dimming the lights
  • Minimizing noise

LABOR

  • I wish to be able to move around (including walking) and change positions at will throughout labor. Please do not restrict positions unless absolutely necessary.
  • I would like to use a birthing ball, moist heat wrap, massage ball, essential oils and affirmations throughout labor.
  • I would like to eat and drink as needed, including ice chips.
  • I would prefer to keep the number of vaginal exams at a minimum. Please ask for consent.
  • I do not want a hep-loc.
  • I do not wish to have continuous fetal monitoring. Intermittent checks are preferred.
  • I do not wish to have my membranes ruptured.
  • I would prefer to be allowed to try changing positions and other natural methods if the labor seems to stall. (walking, nipple stimulation, etc.)
  • I have been educated on the available pain medications. I will ask for them if I need them. Please do not offer them to me.
  • I prefer to tear and do not want an episiotomy.
  • Please do not verbally guide pushing. I would like to push when I feel the urge.

DELIVERY

  • I would like to be able to choose the position in which I give birth.
  • I would appreciate having the room lights turned low and having the room as quiet as possibly for the actual delivery.
  • I would like to have the baby placed on my stomach/ chest immediately after delivery.
  • Please delay the cutting of the umbilical cord until it has stopped pulsating.
  • I wish to keep the placenta. Cooler has been brought for transport to home.

 IMMEDIATELY AFTER DELIVERY

  • My partner wishes to cut the cord. In an event s/he is unavailable, the doula will cut it.
  • I plan to keep the baby near me following the birth and would appreciate if the evaluation of the baby can be done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation.
  • I do not want eye ointment on my baby.
  • Please delay Hep B shot. We will discuss this with our pediatrician at our first visit.
  • Please administer Vitamin K.
  • If the baby must be taken from me for medical treatment, it is requested that my partner be with the baby at all times.
  • I would like to hold baby for one hour before he/she is examined.
  • In case of emergency, please do not cut the cord during resuscitation.
  • I do not wish to be separated from baby. Please speak with my partner or me first if required for health reasons.

BREASTFEEDING

  • I plan to breastfeed the baby and would like to begin nursing the baby right after birth.
  • I do not wish the baby to be given a pacifier.

 CESAREAN

  • If a cesarean delivery is needed, I would like my support team to be fully engaged in the decision making process.
  • I would like my partner to be present at all times.
  • If the baby is not in distress, I would like he/she to be placed on my chest immediately after delivery. If this is not possible, I would like baby to be given to my partner for skin to skin.
  • If baby is in distress, I would like my doula to be with baby at all times and my partner to remain with me.
  • I would like to attempt breastfeeding as soon as possible.

 

 

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