Plan, Sample 7
*If any of the items on
this birthing plan are not possible or permissible please feel
free to discuss those openly with me. I will be happy to accommodate
any reasonable modifications to protect the welfare of the baby
and to respect the midwives, medical staff and hospital policy
as long as the changes are openly discussed with me prior to
any alteration of the birthing plan. I understand that unforeseen
medical circumstances may necessitate variations from our wishes.
During the first stage of labor, I intend
to be at home with my husband, my doula and my mother. We intend
to leave to the hospital once the contractions are 4 minutes
I would like to give birth in a tub equipped
labor/delivery room in ___________ Hospital.
In my labor/delivery room the following
is important to me:
An alternative to the word "pain" and/or anything
else that is negative: I have no pre-conceived notions of pain
during labor and would like to avoid being conditioned to expect
Quiet (Soft) Voices
Hypnobirthing CD's playing softly (probably through headphones)
Lavender linen spray from home
My body pillow
A labor tub
I would like to have my midwife, my mother,
my husband, and my doula in the birthing room with me.
I would like to stay hydrated by drinking
distilled water that we bring from home.
In preparation for my delivery, I would
Not to use an enema.
Not to have epidural offered to me. If I find it necessary,
I will ask for it.
Not to have a routine IV.
Not to be bound to anything that restricts my movement
Not to have routine catheterization.
Not to be medically induced unless I approve it.
Intermittent or portable fetal monitoring
I prefer the following natural methods
of induction before the suggestion of oxytocin/syntocinon (Pitocin),
Any other natural methods that my midwife or doula suggests
I prefer to manage my contractions
by the following methods:
Massage from my husband
Breathing & Relaxation
Positioning and Massage by my doula
Unless it is medically necessary, I would
prefer not to have an episiotomy offered to me. In the event
that an episiotomy is necessary or there is risk of severe tearing,
I would like a local anesthetic to be offered.
I prefer to give birth in a squatting
or kneeling position.
I would prefer infrequent internal medical
exams. I prefer that internal exams are done by my midwife.
During the birth (pushing,
If an assisted birth becomes medically necessary,
I prefer forceps over vacuum extraction, if possible
I would like a mirror available to see my baby's head
I do not want residents or students to be present
As much as possible, I prefer that only my midwife, my
doula or my husband speak to me during the birth.
I request that cell phones/pagers be silent in my labor/delivery
room to avoid unnecessary distractions from hypnobirthing.
We will be banking the baby's cord blood
with CryoCell International.
My husband would like to cut the umbilical
cord if permissible.
If oro-nasal suctioning is necessary,
I prefer that my midwife or a pediatrician perform the suctioning.
I prefer to postpone weighing the baby
and administering eye drops until after I have met him/her.
I would like to hold and breastfeed the
baby immediately after birth, if possible.
If a c-section becomes necessary, I
would like the following:
My husband and doula to stay with me at all times before,
during and after the operation
To be conscious (no general anesthesia)
To have one hand free to touch the baby
Immediate contact with the baby
To nurse the baby within one hour of his/her birth
My husband would like to be present at
the weighing of the baby, administration of eye drops, first
pediatric exam and baby's first bath (accompany the baby to
If my newborn leaves my presence for any
reason, I would like my husband to accompany him/her.
I would prefer a room with a view of the lovely garden.
I would like 24-hour rooming-in with my baby.
I would like my husband to spend the night in my room.
I plan to nurse the baby according to
his/her hunger, unless it becomes necessary to nurse according
to a schedule.
Please do not feed the baby formula
or offer the baby any artificial nipples.
If the baby is a boy, we would like him
to be circumcised in the hospital.
If possible, any postpartum procedures
or medications that would interfere with breastfeeding should