Standard Birth Plan
PATIENT LABEL
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Birth Plan
Planning for the birth of your baby is an exciting time. You have many choices to make for your labor,
delivery and postpartum stay with us. The Birth Plan will help you identify and communicate your wishes to
your healthcare team. Please take some time to talk with your spouse/labor support person about the
options you have available to you. Then, fill in this plan and give copies to the following people:
• Your healthcare provider (physician/midwife)
• The staff at the hospital (bring a copy in your labor bag)
Think of the Birth Plan as a way to tell us about your preferences for your birth experience. Please
understand that your options may change due to the medical condition of you or your baby. However, we
will work to honor your choices and include you in any additional decision making related to your care.
We wish you a wonderful Birth-Day!
Preparation for Childbirth
I attended a prepared childbirth or childbirth update class.
I attended a breastfeeding class.
I did not attend any prenatal classes.
Baby’s Gender
My baby is a boy. His name is ________________________________.
My baby is a girl. Her name is ________________________________.
I do not know my baby’s gender. At the time of birth, I would like to have
_____________________________________ announce the baby’s gender.
My labor support
My primary support person will be _________________________________________________
In addition, ____________________________________ will be providing support during labor.
I will have a doula present to help during my labor/birth: _______________________________
Environment in Labor Room
I will bring my own music.
I would like to have the lights dimmed.
I would like to keep the room as quiet as possible.
Hydration/Oral Fluids
A saline lock (an IV catheter capped with a small plug) is the minimum standard of care based on ACOG guidelines.
I would like to have clear fluids during my labor (examples - water, ice chips, Gatorade®, clear
juices)
I would prefer to have fluids through an IV
IV fluids will be necessary with an epidural. Please discuss this with your healthcare provider
.
Fetal Monitoring
If I meet low risk criteria, I would like intermittent fetal monitoring.
I would like to have my baby monitored continuously with an external fetal monitor.
www.acog.org
has information about the American College of Obstetricians guidelines for fetal monitoring
Form# 10BIRTHPLAN Rev 9/10
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Standard Birth Plan PDF
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