Birth Plan Template printable pdf download

Birth Plan Template

birth plan

Birth Plan Template

Use this easy fill-in-the-blank birth plan to prepare yourself for delivery and communicate your wants and needs

to your medical team.

Full name:

Partner’s name:

Today’s date:

Due date/Induction date:

Doctor’s name:

Hospital name:

Please note that I:

My delivery is planned as:

Have group B strep

Vaginal

Am Rh incompatibility with baby

C-section

Have gestational diabetes

Water birth

VBAC

I’d like...

Partner:

Parents:

Other children:

Doula:

Other:

...present before AND/OR during labor

During labor I’d like...

Music played (I will provide)

To wear my own clothes

The lights dimmed

To wear my contact lens the entire time

The room as quiet as possible

My partner to film AND/OR take pictures

As few interruptions as possible

My partner to be present the entire time

As few vaginal exams as possible

To stay hydrated with clear liquids & ice chips

Hospital staff limited to my own doctor

To eat and drink as approved by my doctor

and nurses (no students, residents or

interns present)

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Birth Plan Template