Blank Birth Plan Template
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We!are!excited!to!share!in!the!birth!of!your!baby!!Our!goal!is!for!you!to!have!the!safest!and!
most!rewarding!experience!possible.!As!you!make!decisions!regarding!your!birth!experience!
we!encourage!you!to!discuss!them!with!your!physician!or!Midwife.!Completing!this!Birth!Plan!
will!help!us!get!to!know!you!and!tailor!our!care!for!you!and!your!family.!!
Please!remember!that!as!your!health!care!needs!change,!so!may!your!birth!plan.!!
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We!are!committed!to!help!you!achieve!the!birth!experience!you!and!your!family!desire.!
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My!Name:!_________________________Due!Date:!________________!
Lab or!Compani ons:!__________________________________________!
Healthcar e!Provider:!__________________________________________!
During Labor I Prefer…
Dimmed Lighting
Music played (I will provide)
To bring items in from home like blankets, aromatherapy scents, massage oil.
The room as quiet as possible
To wear my own clothing
To walk during early labor and try multiple positions during labor
I understand that if I get an epidural I will be confined to bed
I would like to stay hydrated with clear liquids whenever possible during labor
A saline lock if the placement of an IV is needed for hydration during labor.
To be intermittently monitored in early labor so I can walk and move freely.
To walk while being monitored by telemetry.
For Pain Relief…
Nonmedical Options:
I’d like to use relaxation techniques such as:
Various labor positions
Visualization Massage
Birthing Ball Breathing Techniques
Tub/Shower
Hot/cold packs
Medical Options:
Analgesics (Narcotics) Epidural
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Congra tulations,on,Choosi ng,Sarasota,Memorial!,
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