Birth Plan
Sample I

My Actual Birth Plan

Below is a copy of my actual Birth Plan.  It is included on the main site.  However, there it's in pdf format, which doesn't allow you to easily edit it.   If you'd like to use it as a starting point for developing your own, then just copy and paste it into a Word document and go crazy!


We have prepared this Birth Plan to help you understand our philosophy and the kind of care we hope to have for the birth of our child.  We have chosen our doctor because he shares our desire for a low-intervention birth and respects our need for good communication.  We expect, and trust, that our practitioner will seek our opinion on all issues that may affect our birth experience or that deviate from this plan. We wish for as natural a birth as possible, avoiding unnecessary procedures and medications. 

We would like to direct, but know we cannot control, our childbirth experience.  When this Birth Plan is respected, then, if we need to deviate from its general guidelines, we will feel better about the change.  Let us know right away if you think we need to change plans, and why the change is necessary.  We would like to be part of the decision-making team and to be consulted about and asked for our consent before any medical procedure is performed.  In addition, we would like any medical procedure explained as it is performed.  We fully realize that emergencies can happen, and that in the case of an emergency, the health care team will take the best steps for our family.

•    It is important to us that we remain together at all times during the labor and delivery (vaginal or cesarean).
•    While we understand and can appreciate the need for training and teaching, we highly value our privacy and would like to keep the birth team to the minimum necessary number, which excludes residents, trainees, and other nonessential personnel.

•    No routine enema
•    No shaving or removal of pubic hair.

•    Lights dimmed
•    Voices respectfully lowered
•    Prefer option to film and/or photograph
•    Prefer freedom to choose positions and activity level in labor as long as cord prolapse is not an issue.
•    Pain relief through Hypnobirthing relaxation techniques, breathing, massage, counter-pressure, changes in position, water (tub/shower) and emotional support.
•    No pain medications to be offered unless requested.
•    If available, I would like access to a tub, squatting bar, birthing ball, and rocking chair.
•    Ice chips or light beverages upon request.
•    External fetal monitoring only as required by the condition of the baby.
•    We very much want to avoid internal fetal monitoring unless it is specifically medically indicated. 
•    Internal exams for specific medical indication, when labor changes, or by request.
•    Prefer to walk to the bathroom when needed.
•    If catheterization becomes necessary, we prefer to have it removed as soon as possible after bladder is empty.
•    As long as the baby and I are fine, I would like to be free of time limits and not have my labor augmented.
•    If ROM occurs at onset of labor, I prefer to wait 12 hours or more before inducing if our condition permits.
•    If necessary, I would like to try walking, nipple stimulation, and pelvic rocking.


•    Position in pushing phase to be determined by me at the time (using gravity enhanced positioning if possible— includes the possibility of full/partial squatting positions—not flat on back).
•    Pillows, wedge, elevated table back for support at delivery, if necessary.
•    Pain relief through Hypnobirthing relaxation techniques, breathing, massage, counter-pressure, changes in position, water (tub/shower) and emotional support.
•    No pain medications to be offered unless requested.
•    Desire to try for intact perineum with massage, support, and hot compresses.
•    If necessary, we prefer a pressure episiotomy when baby's head is crowning. (Small tear is preferable to a large incision.)
•    Local anesthetic is permissible for performing & repairing an episiotomy.
•    As long as the baby and I are fine, I would like to be free of time limits on pushing.
•    Prefer option of self-directed pushing to help ease the baby out slowly and avoid tearing the perineum.
•    NO LAMAZE-TYPE PROMPTS-we are using Hypnobirthing techniques.
•    If pushing is not progressing efficiently, I would like to be reminded that sometimes changing positions helps.  I would like to be encouraged to try one or more of the following delivery positions: squatting, side-lying, standing upright, hands and knees on floor, kneeling with arms resting on bed/chair, or semi-reclining on bed-knees pressed to chest with support person behind providing counter-pressure.
•    Forceps preferable to vacuum extraction, but prefer to avoid both if possible.
•    Mother would like to be allowed to touch the baby's head as it begins to crown if labor is normal.
•    Mother would like to catch the baby if baby’s condition permits.

•    Baby placed on my chest upon delivery.
•    Father would like to cut the cord.
•    Would like to nurse immediately after delivery if possible.
•    Prefer newborn procedures completed after initial bonding time if possible.
•    Prefer non-irritating eye agent, such as erythromycin or tetracycline, as late as possible.

•    Prefer spontaneous placenta separation with breast stimulation/nursing the baby after delivery rather than inducing with pitocin, uterine massage or cord traction.  If a procedure is necessary, please explain it to me.
•    Perineum ice packs if requested immediately after birth.
•    If fundal massage is necessary I'd like to try it myself, with someone else instructing how.
•    Prefer freedom of movement after birth.
•    Prefer to avoid routine administration of pitocin after the birth if possible.

•    Recovery with baby in private
•    Please hold all phone calls until otherwise instructed
•    24-hour rooming in
•    Breastfeeding on demand with assistance only as requested
•    Prefer to have person of choice in my room at any time of day
•    We would like the option being discharged as soon as possible once our obstetrician has approved it.
•    If the baby is a boy, there will be no circumcision.


•    Prefer to postpone routine newborn procedures until we have had a chance to bond with our baby.
•    Baby held by parents and nursed by mother.
•    Breastfeeding exclusively on demand
•    NO supplementation of any kind—pacifier, sugar water, formula, etc.
•    Suctioning if necessary
•    Prefer all routine procedures done in our room after initial bonding time if possible.
•    If this is not possible, we would like to have father stay with the baby at all times.
•    We prefer that the baby be gently wiped down with a soft cloth to remove fluids, and wrapped in a blanket.
•    Please do not bathe, to allow our baby's natural vernix to continue to soften and protect the skin.
•    Prefer use of oral Vitamin K if possible.
•    We ask that you discuss any additional newborn procedures with us before they are performed.
•    Prefer non-irritating agent, such as erythromycin or tetracycline, as late as possible.
•    If warming is necessary, prefer mother holding baby, with soft cloth/blanket covering both.


•    Please keep communication open. If at all possible, please wait for my express consent, or that of my husband, before initiating any procedure.
•    It is important to me that my husband be present with me at all times during the birth.
•    Ideally, I would like to remain awake and aware, avoiding general anesthesia if possible.
•    Prefer regional anesthesia with little or no premedication or discuss further anesthesia options with me.
•    We prefer that the anesthesia take effect before the catheter is inserted and that there are no "hot spots" (areas which are not yet numb) before the surgery begins.
•    Prefer to have the obstetrician explains events as they occur.
•    Please use a low-transverse incision on my uterus and abdomen.
•    Please leave at least one of my hands free so I may touch our baby when he or she is born.
•    Assuming the baby is well, I would like to hold our baby on my chest.
•    Breastfeeding as soon as possible.
•    We would like the baby's health to be judged on its own merits - no special nursery care unless necessary.
•    Please remove my IV and catheter as soon as possible following our baby's birth.
•    Please provide me with nutritious food and drink as soon as possible.

•    If our baby is not well, we would like to:
•    accompany my baby, or have the father accompany our baby, if transported to another facility.
•    breastfeed exclusively, or provide my expressed milk for our baby.
•    have unlimited visitation.
•    hold, rock and care for our baby, if possible.
•    Visit NICU as much as possible.
•    Have all procedures explained before/as they are performed as our baby’s condition permits.

We thank you for taking the time to go over this Birth Plan, and appreciate your cooperation in getting our new family off to great start!

Physician        Date            Mother            Date            Father        Date