Natural Birth Plan Template
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1NATURAL BIRTH PLAN
Name:
Doctor:
Due Date:
Midwife:
Birth Facility:
Labor Support:
PRE-LABOR
If my approximate due date passes, I would like to avoid inducing labor, provided the baby
and I are in good condition
If my water breaks as I enter labor, I prefer to wait between 24 and 48 hours prior to inducing,
as long as the condition my baby and I are in permits
If I am dilated less than 4 cm, I prefer to return home
MEDICAL PREFERENCES
I do not wish to have any chemical or medical interventions unless my baby or I am in a life-
threatening state
I would prefer to not use IV
I refuse post-birth Pitocin
I will allow vitamin K only orally (no injections)
I do not agree to hepatitis B shot
I do not wish to have eye ointment used on my baby
LABOR PREFERENCES
I prefer intermittent fetal monitoring
I do not agree to stripping of membranes
I prefer hydration through clear fluids
I would rather not have augmented labor
I prefer not having an episiotomy
Before clamping and cutting the umbilical cord, I would like for the pulsating to stop
I prefer breastfeeding my baby directly after birth
I want to keep the placenta
NEWBORN PROCEDURES
I prefer immediate skin to skin contact for 45 minutes prior to any newborn procedures
I would rather my baby not receive a bath
I strongly prefer no pacifiers or bottles
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