My Birth Plan Form
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2My Birth Plan
A birth plan helps you consider your options for labor and the birth process. This plan will also help
you outline your preferences with your health care team. When the time comes, it’s also a good way
to remind yourself of the decisions you made before going into labor. You should discuss this form
with your doctor and your family members.
Name: _______________________________________________________________________________________
Primary care provider: __________________________________________________________________________
OB/GYN: ____________________________________________________________________________________
Midwife/Doula: _______________________________________________________________________________
Other health care provider: ______________________________________________________________________
Where I plan to deliver: ___________________________________________________________________________
Phone: _____________________________________________________________________________________________
Backup hospital (if relevant): ____________________________________________________________________
Phone: _____________________________________________________________________________________________
Partner or labor coach: __________________________________________________________________________
Has medical power of attorney? Yes / No
Other emergency contact: _______________________________________________________________________
In case labor induction is considered:
Unless medically necessary, I prefer not to induce labor until two weeks after my due date.
If my water breaks before contractions start, I prefer to wait at least 12 hours before inducing.
If inducing or augmenting labor becomes necessary, I’d like to try the following techniques (and have made
arrangements in case I need a special practitioner): (Check as many as you like, or number them in the order
you’d like to try each.)
stripping the membranes
cervical dilators
acupuncture or acupressure
prostaglandins (cervidil, Cytotec
®´´
)
castor oil or other laxative
oxytocin (Pitocin,
Syntocinon
)
®´´
®´´
other herbal remedies
breaking amniotic sac (artifi cial rupture)
homeopathic solutions
I plan to have my labor induced. Tentative date: _____________________
Create
a
birth
plan
that’s
right
for
you.
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