Worksheet Template For Preparing Your Birth Plan With Samples (Page 4 of 14) in pdf

Pregnancy, Childbirth, and the Newborn

Sample Birth Plans

We offer here several different examples of birth plans. While individual plans cover many of the same topics, each is written in a

style that reflects the personality and preferred options of the writer.

Note: These are included only as examples of what a birth plan might look like. They are not intended as endorsements or

recommendations of any of the specific details of these personalized plans.

Format/

Preferences for newborn care and

Pain coping

Preferences for labor and birth

Special issues

characteristics

postpartum

Plans for hospital births (in approximate order from lower intervention to higher intervention)

Paragraphs and

Natural, -7 on PMPS,

Avoid routine interventions. Want

Skin-to-skin, delayed cord clamp,

Years of infertility,

bullet-pointed list.

will be disappointed

to use self-help measures. Pushing:

delay procedures 1 hour, no hepatitis

IVF.

Mom, husband,

if takes pain meds.

Upright, avoid tearing/episiotomy.

B, no circumcision, no supplements.

Very modest.

doula.

Has a code word.

Cesarean preferences.

Bullet pointed.

Please do not offer

Lamaze 6 care practices: let labor

Skin-to-skin, breastfeeding. Newborn

Issues with blood

Mom and dad.

pain meds. Plan to

begin on its own, avoid routine inter-

procedures as per midwives’ sugges-

draws.

use music, move-

ventions, upright / water birth.

tions. Family members visiting.

ment, noise, support.

Short letter.

Prefer natural. If ask

Own clothes, music, food, freedom

Gentlest possible transition. Father will

None.

Mother, father,

for epidural, use low-

of movement, bath. Minimize: in-

announce gender. On mom’s chest,

doula.

dose CSE.

terruptions, interventions, vaginal

delay cord clamping, early breast-

exams. Intermittent monitor.

feeding.

Wants / Don’t

Comfort techniques:

Prefer no induction, IV, continuous

Lots of snuggling and nursing. Early

Boyfriend sta-

Wants. Mom,

move, sway, dance,

monitoring. Has a Plan B in the hos-

Skype to Daddy. Wants to learn new-

tioned overseas.

sister.

shower, bath, heat-

pital bag if interventions become

born care skills. May want nurses to

ing pads.

necessary or she chooses pain

take baby overnight.

medications.

Bullet point,

Coping techniques,

Minimize or delay interventions. Sec-

Skin-to-skin, no suction, delayed

Anxiety with

headings for

then probably pain

ond stage: labor down, variety of

clamping, no hepatitis B. Immediate

vaginal exam,

each stage. Mom,

medications in ac-

positions, if possible. Want to avoid

breastfeeding. Request lactation con-

bladder cathe-

husband, doula,

tive labor.

episiotomy, forceps, vacuum.

sultant, education. Visitor preferences.

ter, etc. Inverted

maybe a friend.

nipples.

Grid. Mom,

Epidural in active

Fine with the interventions that

Hold baby. Not sure about skin-to-

boyfriend and 2

labor. (Will use

come with an epidural, but want to

skin—may want baby toweled off first.

friends.

movement and self-

avoid cesarean birth, if possible.

help measures in

early labor.)

Plans for out-of-hospital births and transfers from out-of-hospital births

Short letter. Mom

Prefer natural. May

Preferences: peace, quiet music,

Hold and breastfeed immediately.

Unplanned

and Dad.

choose pain med-

dim lights. Minimal interventions. Re-

Room-in, procedures in arms. Minimal

baby. But look-

ications if needs

alizes a necessary hospital transfer

separation.

ing forward to

painful interventions.

means interventions are likely.

starting family

(even if earlier

than planned).

Hospital transfer / VBAC

Letter with some

Prefer natural, unless

Understands continuous monitor-

Skin-to-skin; delay procedures, do in

Prior cesarean.

bullet points.

epidural would ben-

ing and other interventions may

arms, no supplements.

Prior VBAC.

Mom, husband.

efit labor progress.

be required. No prostaglandins.

Planning VBAC.

2 older children.

Ideally, spontaneous pushing for

VBAC. Family-centered cesarean if

needed.

Plans for VBAC

Table/spread-

Plan to use coping

Don’t offer interventions unless

Delayed cord clamping, donate cord

Drug allergies.

sheet. Mom, wife/

techniques. Don’t

needed. Squat bar, spontaneous

blood, delayed bath, delayed immuni-

VBAC.

mama. Grand-

offer medications.

pushing in a variety of positions,

zation, no circumcision.

ma-to-be.

mirror.

Cesarean birth plan

Short letter. Single

Will have pain medi-

Planned cesarean for breech baby.

Delayed cord clamping, skin-to-skin

mom by choice.

cations.

Requests (and defines) family cen-

and breastfeeding in OR. Procedures

Sister, male friend

tered cesarean.

delayed until baby has nursed.

who is nurse.

Worksheet Template For Preparing Your Birth Plan With Samples Page 4

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