Birth Plan Sample
A birth plan is designed to facilitate communication between you and your provider, especially necessary if you are birthing outside the home environment. Secondly, it is to offer information on the individualized care you as the mother would like during labor, birth and immediately postpartum for you and your baby.
It should be brief (no more than one page) and only have the bullet point information that is specific to individualized care and desires not usually within your care provider’s standing orders or usual protocols of the birth location.
It is important to take a written birth plan to a prenatal visit at least a month prior to your given estimated due date in order to have a clear understanding of expectation and agreement. If it becomes apparent that you and your provider are not on the same page, this gives can give time to seek out another provider that fits you and you fit with. Remember it is not a legal document that your location of delivery or care provider must adhere to.
Birth Needs and Desires for: _______________________.
Estimated Due Date: _________________.
I am planning on a no to low-intervention natural birth. I plan on being mobile, lightly snacking, drinking orally, and having ___________ present. I understand that intermittent monitoring of me and my baby will be necessary. I want to be fully consented for any procedure that may come up and fully participate in the medical care for myself and my baby. I understand that there is pain management available to me, I will ask for it if I so desire.
- I plan on wearing my own clothing. I will ask for a gown if I change my mind.
- I would like a saline lock in lieu of a running IV.
- Limited vaginal exams after initial assessment.
- In the event an induction and/or augmentation is medically necessitated-
- Ripening – Foley Catheter instead of Cytotec (misoprostol), Cervadil or Prepadil
- Pitocin – A very gentle and slowly administered dosage increase.
- AROM – will only consent to if an internal fetal monitor is a must.
- Spontaneous pushing and delivery in any position I am most comfortable with.
- No cord traction or aggressive placental detachment, including deep uterine massage.
- Delayed cord clamping for at least 10 minutes or until my placenta spontaneously detaches (baby can receive oxygen or other assistance while still attached to me).
Postpartum and Baby Care
- Request that my baby is on my belly or chest for assessments and warmth (even oxygen can be given on me)
- Delayed bathing
- Delaying vaccinations including eye ointment and vitamin k.
- Exclusive breastfeeding, no pacifiers, sugar water, or formula. I will hand express if necessary.
- No separation from me unless absolutely medically necessary not just protocol.
Cesarean: In the event a cesarean becomes necessary and is not a true emergency requiring general anesthesia. I would like to keep the spirit of my plan A to plan C so the delivery can be as family centered and intimate as possible.
- Only essential conversation related to the surgery and delivery
- Lower sterile drape or have a mirror present so I may see my baby emerge
- Only one arm strapped down so I may touch my baby
- Aromatherapy as I desire for comfort, abate nausea and to mask surgical odors
- Baby to stay with me continuously in OR and recovery
- If baby must leave OR for treatment, my partner/spouse goes with baby and I would like my ____________ to stay with me so I am never alone.
- Breastfeed in OR and/or recovery
- Delayed immunizations
- Delayed washing and dressing of baby
- No separation from me except what is absolutely medically necessary
This “plan” may be copied, pasted and edited for use by others.