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Birth Plan Template

This birth plan outlines the mother's preferences for labor, delivery, and postpartum care. She plans to give birth at a hospital with her obstetrician and doula present. During labor, she wants to remain active and use massage and hot towels for pain relief. She prefers minimal cervical exams and no monitoring unless medically necessary. Following delivery, she wants immediate skin-to-skin contact and delayed cord clamping. She also wants to hold the placenta and have the baby examined in her presence. In the event of a c-section, she wants her partner present and a description of the procedure.

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Cherry Savannah Abenojar
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1K views3 pages

Birth Plan Template

This birth plan outlines the mother's preferences for labor, delivery, and postpartum care. She plans to give birth at a hospital with her obstetrician and doula present. During labor, she wants to remain active and use massage and hot towels for pain relief. She prefers minimal cervical exams and no monitoring unless medically necessary. Following delivery, she wants immediate skin-to-skin contact and delayed cord clamping. She also wants to hold the placenta and have the baby examined in her presence. In the event of a c-section, she wants her partner present and a description of the procedure.

Uploaded by

Cherry Savannah Abenojar
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Birth Plan
  • Labor & Birth Preferences
  • Special Care Preferences

Birth Plan Name: ____________________________________________

Partner's name: ____________________________________________ Due date: ____________________________________________

Name of obstetrician / midwife: ________________________________ Other birth-support (doula, other family): ________________________ _________________________________________________________

Where do you want to give birth? Hospital (name of hospital) _______________________________ Health Center (name of health center) ___________________________ At home Not sure yet Things to bring: For Mothers: registration card/health record clothes maternity sanitary pads undies nursing bras toiletries (hairbrush, shampoo, make-up, tissues, deodorant, toothbrush, toothpaste, etc)

For baby: wipes socks / booties scratch mittens baby bath solution / baby wash towels clothes

Labor & Birth Mobility during Labor I would like to keep active during labor if possible (walking, fitball, etc.) Mobility is not important to me Relaxation and Comfort during Labor Massage Bath Hot towels Position(s) for Labor & Birth Walking Standing Squatting Sitting Kneeling Lying down Birth Stool Vaginal / Cervix Examinations I would like minimal examinations I am happy for examinations as deemed necessary by medical staff No monitoring - except in emergency situations Pain Relief Do not offer; I will ask if I want pain relief Offer if I appear uncomfortable Offer as soon as possible Episiotomy I do not want an episiotomy unless there is an emergency situation I would like an episiotomy to reduce the risk of tearing Immediately following delivery I want baby placed on my chest immediately after birth Please delay cord clamping and cutting until pulsating ceases I would like to hold the baby while the placenta is delivered I would like the baby to be examined in my presence

If the baby cannot be examined in my presence, I would like my birth-partner to remain with the baby at all times Caesarean In the event that a cesarean section is deemed necessary, I would like the following: Birth-partner present Other support present ______________________________________ Photos / video Screen lowered at delivery I would like the procedure described as it is happening In the event that baby requires special care due to trauma or illness I would like to breastfeed/pump breast milk Birth-partner will accompany baby if transferred to another hospital I would like to be transferred to baby's hospital

Signature _________________________________

Date _________

Healthcare Provider's Name _____________________________________ Healthcare Provider's Signature ____________________ Date _________

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