Blank Birth Plan Template
If my labor slows down, I would:
First like to try nonmedical methods like walking and using upright forward leaning labor
Prefer that my practitioner breaks my bag of waters.
Prefer that my bag of waters breaks on its own.
Prefer to receive an IV of Pitocin only after all other methods are tried, and only if medically
During!P ushing!I!would!like …!
To wait to push until I feel the urge or until my baby descends.
To use a variety of positions during pushing.
A mirror placed at the foot of the bed so I can watch my baby’s birth.
I would like to be directed as to when to push.
I prefer any natural tearing over an episiotomy.
I would like to avoid forceps and/or vacuum extraction unless absolutely necessary.
I would like to touch my baby’s head as it crowns.
I would like __________________ to cut the umbilical the cord on the warmer.
I am interested in delayed cord clamping.
I would like to bank my baby’s umbilical cord blood and have talked with my caregiver
I would prefer that routine hospital procedures be done while I hold my baby if possible.
I would like all routine shots and drops for my newborn delayed if possible.
I am breastfeeding exclusively.
I plan to formula feed only.
In!Ca se!of! a!Ces arean!Birt h…!
If possible, I would like _________ to accompany me into the OR. (add name )
If anesthesia is a choice for me, I would prefer an epidural.
If anesthesia is a choice for me, I would prefer a spinal.
I would like the sterile blue drape lowered for the birth.
I would like my support person to cut the cord on the warmer.
I would like to have at least one arm released so I can hold my baby right away if
permitted and the baby’s medical condition is stable.
I would like to breastfeed as soon as possible in the recovery room.
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