Sample Birth Plan Template

I would like to hold baby:
Immediately after delivery
After suctioning
After weighing
After being wiped clean and swaddled
Before eye drops/ointment are given
I would like to breastfeed:
As soon as possible after delivery
Before eye drops/ointment are given
Later
Never
Immediately after delivery, I would like:
My partner to cut the umbilical cord
The umbilical cord to be cut only after it
stops pulsating
To bank the cord blood
To donate the cord blood
To deliver the placenta spontaneously and
without assistance
To see the placenta before it is discarded
Not to be given Pitocin/oxytocin
I would like my family members:
(names:)
To join me and baby immediately after
delivery
To join me and baby in the room later
Only to see baby in the nursery
To have unlimited visiting after birth
If a C-section is necessary, I would like:
A second opinion
To make sure all other options have been
exhausted
To stay conscious
My partner to remain with me the entire
time
The screen lowered so I can watch baby
come out
My hands left free so I can touch the baby
The surgery explained as it happens
An epidural for anesthesia
My partner to hold the baby as soon as possible
To breastfeed in the recovery room
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birth plan
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Sample Birth Plan Template PDF

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