Standard Birth Plan
PATIENT LABEL
PermanentPartofMedicalRecord Page3of3
Vaginal Birth
I would like to:
view the birth using a mirror.
touch my baby’s head as it crowns.
avoid having an episiotomy (an incision to enlarge the vaginal opening for birth).
Other: _________________________________________________________________________
_________________________________________________________________________
Cutting the umbilical cord:
I would like to have _____________________________________ cut the cord.
My labor partner does not want to cut the umbilical cord.
Greeting My Baby
I would like to:
have the baby placed skin-to-skin on my abdomen immediately after birth.
have my baby cleaned off before being placed skin-to-skin.
hold my baby as soon as possible, putting off procedures that aren’t urgent.
Infant Feeding
During my stay in the hospital:
I plan to breastfeed.
I plan to formula feed.
Circumcision
If my baby is boy:
I do not want to have him circumcised.
I would like to have him circumcised at the hospital.
I will have him circumcised later.
Cesarean Birth
If I have a cesarean birth (surgical delivery of my baby through an abdominal incision), I would like
to have:
my labor support person present.
the umbilical cord left long so my labor support person can cut it shorter.
the baby given to my labor support person as soon as possible.
Other: _________________________________________________________________________
Please help us understand any additional preferences you have for your birth experience. You may have
special routines, traditions or expectations that are part of your beliefs about birth or family/faith heritage.
The more information you can share with us, the better we are able to meet your needs during your stay at
Methodist Women’s Hospital.
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Patient Signature Date
________________________________________________________ __________________________
Provider Signature Date
Form# 10BIRTHPLAN Rev 9/10
Page 3/3
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Standard Birth Plan PDF
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