Last Updated on 01/28/2021 by Mama Must Have
This birth plan template will help you identify what you would desire your birthing process to be like. Remember that with the birth of a baby, things do not always go as planned. Have your birth plan ready, but be flexible to changes that may need to take place.
Mother’s Name: ___________________________ Father’s Name: ______________________________
Doula: ___________________________________ Expected Delivery Date: _______________________
Support Person(s):______________________________________________________________________
Support Person(s) Contact Info: ___________________________________________________________
Labor & Delivery:
- Preferred birthing technique – Bradley method, hypnobirthing, relaxation techniques, music, etc.
- Preferred method of delivery – Vaginal Birth, Unmedicated Birth, Scheduled Cesarean, Vaginal Birth after C-Section, Scheduled Induction
- Preferred methods of assistance – Amniotomy, Forceps delivery, Vacuum extraction, Episiotomy, Induction
- Preferred position of delivery – sitting, moving, lying down, bath tub (if permitted by birthing facility)
- Do you want any medication to help with the labor pains? (Epidural, spinal block, nitrous oxide)
- What do you want to do while you labor? (Walk around, birthing ball, birthing stool, TENS machine, hypnosis, reflexology, etc.)
- What do you prefer to wear during labor? (Hospital gown, own clothes)
- Do you want photos taken?
- Do you want cervix checks?
- Do you want to have a mirror to watch the birth?
- Do you want either you or your support person to catch the baby?
If Cesarean is needed:
- Who would you prefer to be present with you?
- Who should stay with the baby if baby would need to leave the room for any reason?
After Birth:
- Do you want baby placed on you or your partner for skin-to-skin contact?
- Do you prefer to delay cord clamping? Who do you want to cut the umbilical cord?
- Do you want baby to stay with you or go to the nursery?
- Do you plan to breastfeed or formula feed?
- Do you want your baby to receive vaccinations, eye ointment, and vitamin k shot?
- What do you plan to do with the placenta and baby’s cord blood?
- When would you prefer your baby to have the first bath?
Be sure to discuss these things with your support person(s) so that they are also aware of the decisions to be made in case you are not able to make the decisions. Remember again that this is just a birth plan template and it is likely that things may go very differently.