Sample Birth Plan Template

Full name: Partner’s name:
Doctor’s name: Hospital name:
Please note that I:
Have group B strep
Am Rh incompatibility with baby
Have gestational diabetes
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Today’s date:
Due date/Induction date:
My delivery is planned as:
Vaginal
C-section
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)
The lights dimmed
The room as quiet as possible
As few interruptions as possible
As few vaginal exams as possible
Hospital staff limited to my own doctor
and nurses (no students, residents or
interns present)
To wear my own clothes
To wear my contact lens the entire time
My partner to film AND/OR take pictures
My partner to be present the entire time
To stay hydrated with clear liquids & ice chips
To eat and drink as approved by my doctor
Use this easy fill-in-the-blank birth plan to prepare yourself for delivery and communicate your wants and needs
to your medical team.
birth plan
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Sample Birth Plan Template PDF

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