Sample Birth Plan Template

I’d like to spend the first stage of labor:
Standing up
Lying down
Walking around
In the shower
In the bathub
I’m not interested in:
An enema
Shaving of my pubic area
A urinary catheter
An IV, unless I’m dehydrated (and a
heparin or saline lock IS/IS NOT okay)
I’d like fetal monitoring to be:
Continuous
Intermittent
Internal
External
Performed only by Doppler
Performed only if the baby is in distress
I’d like labor augmentation:
Performed only if baby is in distress
First attempted by natural methods such
as nipple stimulation
Performed by membrane stripping
Performed with prostaglandin gel
Performed with Pitocin
Performed by rupture of the membrane
Performed by stripping of the membrane
Never to include an artificial rupture of
the membrane
For pain relief I’d like to use:
Acupressure
Acupuncture
Breathing techniques
Cold therapy
Demerol
Distraction
Hot therapy
Hypnosis
Massage
Meditation
Reflexology
Standard epidural
TENS
Walking epidural
Nothing
Only what I request at the time
Whatever is suggested at the time
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Sample Birth Plan Template PDF

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