Birth Plan Template


Birth Plan
Full Name:____________________ Partner’s Name:______________________
Provider: OB-GYN, P.C.
*I would like ______________________________________________________
present in the delivery room with me.
*You should know that I
_____ have group strep B
_____am Rh negative
_____have gestational diabetes
*Having access to a birth ball/peanut/bean bag/squatting bar/bath tub are,
_____ Important to me.
_____ NOT important to me, but if you find they may be helpful, please suggest them to me.
*For Pain relief I would like,
_____to know my options immediately
_____to NOT be offered any pain meds unless I request them
_____to use breathing, positioning, and relaxation techniques
*As baby is being delivered/when baby is delivered, I would like,
_____ to touch baby’s head as it crowns/help catch the baby
_____ to do skin to skin care immediately
_____ to allow the cord to be done pulsating before it is clamped
_____ to donate cord blood to Michigan Blood
_____ to collect cord blood for private banking
_____ to have partner cut the cord


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