Birth Plan

This Birth plan is for __________________________________________________

This birth plan is intended to express my/our desires I/we have for the birth of my/our baby. I/we realize that in certain circumstances these requests may not be followed, but it is my hope that you will assist me/us in making this the experience I/we hope for. Mostly I am/we are asking you to keep me/us informed of my/our options. If you have any questions or suggestions, please let me/us know. 

First stage of labor:

Environment: check as many as you would prefer.

_____Dim lights

_____Peace and quite


_____Wear my own clothes              

_____Minimal vaginal exams

_____Other  (please specify)


_____I wish to be able to move around and change position at will throughout labor

_____Freedom to move in bed only (up to bathroom only)

_____Mobility not important (I plan on having an epidural)


_____ No restriction (would like to eat and drink whatever I am comfortable)

_____ Clear fluids

_____ Ice chips

_____ Heparin/Saline lock (most hospitals require access to a vein should an emergency occur, or complications needing antibiotics such as Positive Group Beta Strep)

_____ IV (you will need an IV if you plan on using pain medication through the IV or an epidural)

_____ If no risk factors would like no IV unless my provider says I need one


_____ Intermittent monitoring

_____ Continuous external monitoring

_____ Continuous internal monitoring

The decision about type of fetal monitoring will not always be left up to the parents, if there is a question as to the health (I.e. fetal distress) of your baby we may need to monitor more closely.

Pain Relief Offers:

_____ Please do not offer me medication. I will ask if I need assistance.

_____ Offer if I appear uncomfortable

_____ Offer as soon as possible

Pain Relief Options:

_____ Non-Medicinal: Positioning; shower or tub; heat or cold therapy; massage; acupressure

_____ IV Medication

_____ Epidural


Usually induction/augmentation are not discussed in a birth plan. If you require an induction the decision will usually be made before you arrive at the hospital. However, it is important to know that you have options.


_____ Natural methods (walking, nipple stimulation, sex)

_____ Herbal inductions (not available in all locations)

_____ Prostaglandin gel (recommended if you have an “unfavorable cervix”)

_____ Cytotec (oral or vaginal tablet, also recommended for “unfavorable cervix”, not used if prior C/Section)

_____ Pitocin (synthetic hormone given in the IV to start contractions)

_____ Amniotomy (break the water)


_____ Natural methods (walking, nipple stimulation)

_____ Pitocin (see above)

_____ Amniotomy (see above)

Second Stage of Labor:


_____ I would like to take pictures while in labor, of the birth, after the birth

_____ I would like to make a video recording of my labor, birth, after the birth

Some hospitals require you to get the permission of the provider doing your delivery prior to taking pictures or video taping of the birth


Some of these will depend on if you are medicated, how your labor is going, and the health of your baby.

_____ Choice of positions (certain positions are better for encouraging the baby to come down)

_____ Push as long as I can/want (Ask about “time limits” for pushing)

_____ Spontaneous bearing down (push when your body tells you to push)

_____ Directed pushing (Being told when to push, how long to push “counting”)

_____ Prefer to use people for leg support (as opposed to stirrups or foot pedals)

_____ Foot pedals

_____ Squat bar

_____ Stirrups (sometimes used if epidural is too heavy and mom can’t feel legs)

Perineal Care:

_____ Prefer no episiotomy (massage, compresses, positioning, tearing)

_____ Prefer episiotomy

Baby Care:

_____ If baby is in no distress place on my stomach/chest immediately

_____ Place baby on warmer and clean up before being brought to me

Cord Cutting:

_____ Partner cut cord

_____ I want to cut cord

_____ Immediately cut cord

_____ Delayed until cord stops pulsating

_____ I am a cord blood donor and have made arrangements

Eye Care:

_____ None

_____ Delayed for ______ minutes

_____ Immediate

Feeding Baby:

_____ Breast feeding only

_____ Bottle feeding only

_____ Combination

_____ No pacifiers


_____ Would like to have exam and first bath in my presence

_____ If baby needs to be taken away from my side for medical attention, I want _____________________ to accompany baby at all times

If infant is sick would like:

_____ Breast-feeding as possible

_____ Breast pump available

_____ Unlimited visitation for parents

_____ Help care for infant (hold, change diapers, etc)

_____ If baby is transported to another facility, move as soon as possible


_____ None

_____ For cultural or religious reasons will be done outside the hospital

_____ Done in hospital

_____ Use of anesthesia (need to ask at time of circumcision)


Unfortunately not all mothers will deliver vaginally. It is important to know the Cesarean Section rate at your hospital. The National average is 25% Cesarean Section births. If you have a planned or unplanned non-emergent cesarean birth you can still discuss some options with your physician.

_____ Spinal/epidural anesthesia

_____ General anesthesia (being put to sleep)

_____ Partner present

_____ Pictures/Video of birth

_____ Screen lowered to view birth

_____ Description of surgery

_____ Touch the baby

_____ Breast-feeding in recovery room

Remember in the event of an emergency regarding your health or the health of your unborn baby we will do our best to keep you informed but we may need to shift from your birth plan.