Fertility

Birth Plan Template: How To Create A Birth Plan & What To Include In Yours

Updated on 15 June 2021 • 7 minute read
Views

 

Overview

Is your due date fast approaching? Giving birth can be exciting yet also overwhelming for a woman, especially if you’re a first-time mom. 

That’s why it helps to be prepared. Do you already have a name picked out for your baby? The next step would be to plan for your little one’s arrival by creating a birth plan

It can make you feel more confident on your big day, whether you’re aiming for a natural birth or are due for a cesarean section

While deliveries can be unpredictable, it’s still a good idea to be prepared, even for the unexpected. 

You can use our free birth plan template to create your birthing plan and be prepared for your little one’s arrival, mama.

 

Free Birth Plan Template

Creating a birth plan can be difficult, especially if you’re a first-time mom. But our free template can help you cover everything you need before, during, and after delivery.

Here’s our sample birth plan:

 

Basic Information

  • Name: __________________________
  • Spouse’s name: __________________________
  • Main support person‘s name or doula: ________________________
  • Birthing center or hospital: __________________________
  • Due date or induction date: __________________________
  • Health care provider/OB-GYN: __________________________
  • Baby’s pediatrician: __________________________

 

Information & Requests Before Labor

My planned delivery type is:

  • Vaginal birth
  • C-section
  • Waterbirth
  • VBAC (vaginal birth after cesarean section)

 

My health conditions or factors (circle all that apply):

  • I have allergies to: __________________________
  • I have group B strep
  • I am Rh incompatible with baby
  • I have gestational diabetes
  • Other medical conditions: __________________________
  • Medications I’m taking: __________________________
  • Others:  __________________________

 

People on my birth team

  • My partner
  • My parents
  • My children
  • My doula
  • My midwife
  • My OB-GYN
  • Others: __________________________

 

Requests During Labor

If possible, I’d like to (circle all that apply):

  • Try water birth or labor in water (birthing tub or in-room shower)
  • Be out of bed (sitting up or walking around) during labor
  • Eat and drink during labor (if practitioner allows)
  • Listen to music and have dim lighting
  • Have a quiet delivery room, if possible
  • Use essential oils 
  • Have my birth doula present during labor
  • Have my support person take photos or videos
  • Have hospital staff limited only to my doctor and nurses (no residents, interns, or students during labor and birth)
  • Have as few interruptions as possible
  • Wear a hospital gown
  • Wear my own delivery gown or clothes
  • Don’t shave my pubic area
  • Other requests: __________________________

 

Birthing Positions I’d Like To Use

  • Standing or walking
  • Rocking
  • Squatting
  • Sitting
  • Kneeling or leaning over
  • Going on all fours (hands and knees)
  • Lying on your side
  • Semi-reline (half sitting up or lying down)
  • Leaning on my partner
  • Use a birth bar for support
  • Use foot pedals for support
  • Use people for leg support
  • Use a birthing stool
  • Use a birthing ball
  • Use a birthing chair
  • Use a birthing tub
  • Use a squatting bar

 

Fetal Monitoring

  • Continuous
  • Intermittent
  • External electronic device 
  • Internal device
  • Doppler fetal monitoring only
  • Fetal monitoring only if the baby is in distress

 

Labor Intervention & Augmentation

My preferences are (circle all that apply):

  • Artificial rupture of membranes
  • Keep my membranes intact for as long as possible
  • Use IV (intravenous)
  • Use saline or heplock (heparin lock)
  • Use catheter
  • Use enema
  • Use Pitocin (oxytocin injection) to augment or induce labor contractions
  • Use prostaglandin gel
  • Natural perineal tearing only
  • Episiotomy
  • Use vacuum extraction for birth assistance
  • Avoid vacuum extraction
  • Use forceps to assist baby’s delivery
  • Avoid using forceps 
  • Other options: __________________________

 

Pain Management

My preferences to ease labor pain are (circle all that apply):

  • Meditation
  • Breathing techniques and exercises
  • Body massage
  • Perineal massage
  • Counter pressure
  • Reflexology
  • Acupuncture
  • Acupressure
  • Hypnosis
  • Rebozo technique
  • Hydrotherapy
  • Hot or cold therapy
  • Distraction
  • TENS (transcutaneous electrical nerve stimulation) machine
  • Oral pain medication
  • Local anesthesia
  • Standard epidural 
  • Walking epidural
  • No pain relief unless medically necessary
  • Other options: __________________________

 

Delivery Preferences

Unless there’s an emergency, I’d prefer these for my baby’s birth (circle all that apply):

  • Push spontaneously
  • Push without time limits, if medically possible
  • Push as directed
  • Use a mirror to see my baby crown
  • Touch the head as it crowns
  • Let epidural wear off while pushing
  • Have my partner help catch our baby, if medically possible

 

In Case Of A Cesarean Section

If vaginal delivery is not medically possible, I would prefer these before and during C-section (circle all that apply):

  • A second opinion
  • All options for vaginal birth have been exhausted
  • To stay conscious
  • The surgery explained as it happens
  • Have clear drapes or lowered screen so I can watch my baby come out
  • Have one arm free of monitors, cuffs, or IVs so I can hold my baby
  • Have my partner hold the baby first

 

Requests After Labor & Newborn Care

My preferences after delivery (circle all that apply):

  • Let my partner suction our baby
  • Let my partner cut the umbilical cord
  • Clamping of umbilical cord only after it stops pulsating or after ____ minutes.
  • Spontaneously deliver the placenta
  • See the placenta before it’s discarded
  • Take the placenta home 
  • Release my placenta to my doula for placenta encapsulation processing 
  • Hold my baby immediately after birth, skin to skin
  • Give my baby time to crawl from my belly to breast
  • Cord blood banking
  • Donate the cord blood
  • Perform circumcision if my baby is a boy
  • Give vitamin K to my baby
  • Refuse vitamin K 
  • Refuse antibiotic eye treatment
  • Give antibiotic eye treatment to my baby
  • Room-in with baby
  • Have my baby sleep in the nursery
  • Do not bathe or clean my baby
  • Refuse the Hepatitis B vaccine for my baby
  • Other preferences: __________________________

 

Holding My Baby 

  • Immediately after delivery
  • Only after suctioning
  • Only after weighing
  • Only after being cleaned and swaddled
  • Before eye drops or ointment are given

 

Feeding Preferences

  • Give my baby formula
  • Only give breast milk to my baby
  • To breastfeed as soon as possible
  • To breastfeed in the recovery room
  • Have a lactation consultant assist me with breastfeeding

 

Please Don’t Give My Baby (Circle All That Apply):

  • Pacifier
  • Sugar water
  • Vitamin K
  • Antibiotic eye treatment
  • Formula
  • Hepatitis B vaccine

 

Baby’s First Bath

  • By me
  • By my partner
  • In my presence
  • In my partner’s presence
  • Refuse bath

 

If My Baby Is Unwell (Circle All That Apply):

  • My partner and I will accompany our baby to the NICU or another facility
  • To breastfeed, if possible
  • Provide pumped breastmilk
  • To hold my baby whenever possible

 

Birth Plan FAQs

What’s A Birth Plan?

A birth plan is a printable worksheet or written plan through which you make your goals and wishes clear to your health care practitioner and support person before, during, and after your baby’s birth.

It contains information about yourself, previous deliveries, birth preferences, pain relief preferences, and what you want to happen postpartum.

The birth plan can help you feel more confident because you can create the best-case birthing scenario of how you want the delivery to be (if it goes according to plan).

 

Do I Need To Make A Birth Plan?

A birth plan isn’t a mandatory document that your health care practitioner will expect when you arrive at the hospital or birthing center

But having one in your hospital bag can help you feel more prepared for expected and unexpected moments during delivery.

 

When Should I Make A Birth Plan?

More often than not, your OB-GYN will also be the one to deliver your baby. So, it’s a good idea to go over your birth plan with them during your prenatal visits.

It’s practical to make the birth plan close to your due date. But you can do so anytime during the pregnancy, so you can weigh your options and preferences before making a decision.

 

What To Do After Making The Birth Plan?

Once you’re done with your birth plan, it’s a good idea to discuss it with your healthcare provider. The plan can be affected by the following:

  • Your health care provider’s recommendations
  • The birthing center or hospital’s policies
  • Limitations of the birthing center or hospital
  • Medical emergencies during labor and delivery

 

If you’re joining birth classes, you might also get some tips to include in your worksheet.

After making the necessary changes and finalizing your plan, give copies to your doula, midwife, doctor, and support person. You can also bring an extra copy in your hospital bag.

 

What If My Preferences Change During Delivery?

Don’t worry if you suddenly have second thoughts about your plan during delivery, especially about pain management and comfort measures after the labor starts. 

 

Can I Add Requests For My Baby In The Birth Plan?

Of course, you can always add requests to your birth plan, especially about your baby. 

But these requests may be subject to the hospital or birthing center’s policies. So, check those policies first before working on your plan.

 

Do’s and Don’ts in Making a Birth Plan

Don’t Write A Novel.

While you might enjoy writing about your pregnancy and upcoming baby, it’s not something that the busy nurses and doctors have time to read.

If your plan looks so hard to skim through, it might get lost with other paperwork on your chart.

 

Do Keep It Short And Easy To Read.

The goal is to keep your plan thorough yet concise so that your healthcare provider only needs to scan through it and find answers when the need arises.

You don’t have to explain your choices or your reasoning.

 

Don’t Give An Overview Of Your Pregnancy.

During delivery, your pregnancy story wouldn’t matter to the busy doctors. So, there’s no need to provide a play-by-play story of what happened during your pregnancy, how many ultrasounds you’ve had, or what prenatal vitamins you took.

 

Do Provide Relevant Health Information.

But it’s important for your doctor to known relevant health information, such as:

  • Allergies
  • Recent test results
  • Most recent ultrasound results
  • Possible complications (example: your baby was diagnosed with IUGR or intrauterine growth restricted)
  • Trauma history
  • Gestational diabetes
  • High blood pressure
  • Other medical conditions or treatments (example: cancer and relevant treatments)

 

Do Include A Section For C-section.

While the best-case scenario is normal, vaginal delivery, it’s still a good idea to prepare for other possible outcomes.

By already including the possibility of a C-section in your plan, you’ll be more prepared.

 

Do Focus On Things That Matter More To You.

But you don’t have to address every single possible complication that could happen. For example, you might plan to deliver while standing up but find it easier to do it while squatting.

Remember, the doctors and nurses might be too busy with other things to read everything on your birth plan. You might consider asking your team, particularly your doula or support person, to stick with this written plan during delivery.

 

Do Include Your Baby.

You can use our birth plan template above or make your own.

But in preparing your worksheet, always make sure to include your baby in the plan.

For example, it’s important to add your feeding plans, what items should or shouldn’t be given to your baby, and other standard procedures that are done after birth.

 

Don’t Get Sad Or Angry If Things Don’t Go According To Plan.

Having this plan can come in handy, whether you already know that you’ll need a C-section or if you hope for a vaginal birth.

But while it’s an important worksheet you can bring during delivery, always remember that childbirth is unpredictable. Even the best-laid plans can change.

Things might change at the last minute. So, flexibility is also a key part of your birth plan.

 

 

 

as seen on
We Got You, Mama.

Self-Care Rituals & Self-Love Practices To Support You & Your Family.

[gravityform id="6" title="false" description="false" ajax="true"]