Birth Plan Template

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Birth Plan Template

This "worksheet" form is intended to help you get started thinking about things you'd like to include on your own birth plan. It won't include all the options or be in a printable format at the end, so you'll want to use your results to create your own plan. Hopefully this will also help you realize what options you would still like to research, as well.

Be aware that many decisions are connected, so think about how each preference affects the others.

Birth plan for ___________________

Name of mother, father, baby (if decided)

Brief Introduction. Why is this type of birth important to you?

Write a few sentences about your ideals for birth to personalize your plan for those who will assist you

First Stage Labor

Mobility

How important is maintaining freedom of movement to you? (check any that are applicable)

I want total freedom of movement to choose what positions work best for me

I am okay with only laboring on/near the bed

I'm okay not moving, just staying in bed

Please suggest movements/positions that would be helpful

Fetal Monitoring

I prefer..

Intermittent electronic monitoring

Intermittent ascultation

Continuous fetal monitoring

Clear selection

Hydration and Nourishment

Once I arrive at my birthplace...

I will eat and drink to my preference

I am okay with water and ice chips only

Please administer fluids by IV

Pain Relief

Where do you fit on this scale?

I don't want pain medication (Please don't offer)

I'd love an epidural as soon as possible

Clear selection

Labor Augmentation

If labor augmentation is suggested, I'd prefer...

changing positions

walking

nipple stimulation

pitocin

cohosh

I'd prefer...

Second Stage Labor

What are your preferences during pushing and delivery?

Rate how you feel about each of these options

Please avoid, ask me if situation requires

Neutral

I plan on this

Episiotomy

Forceps

Vacuum

Coached (directed) pushing

Mirror to watch birth

Apply compress to perineum

Clear selection

Pushing positions & tools

I'd like to use any or all of the following positions/tools as helpful:

Squatting (with or without squat bar)

Hands and knees

Semi-reclined

Birth stool

Birth tub/pool

Birth ball

Legs in stirrups

Side-lying

Sitting

Partner teamwork (rebozo)

Third Stage

What are your preferences immediately following delivery?

Please clamp and cut the umbilical cord...

To help the placenta deliver...

Avoid unless necessary

Less preferable

More preferable

Start immediately

Baby at the breast

Administer pitocin

Give fundal massage

Administer cytotec for hemorrage if needed

Clear selection

I'd prefer third stage to be

physiological

managed

Clear selection

Submit

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