Plan, Sample 8
_____________ Partner: ___________
Support Person(s): _____________ Due Date: _______
Practitioner: _______________ Place of Birth: _____________
This birth plan is intended to express
the preferences and desires we have for the birth of our baby.
It is not intended as a script. We fully realize that situations
may arise such that our plan cannot and should not be followed.
However, we hope that, barring any extenuating circumstances,
you will be able to guide us toward the birth experience we
If procedures or medications are proposed,
we ask that you discuss them with us and suggest alternative
therapies and comfort measures so that we can make well-informed
We are striving for flexibility on our part, as well as that
of the birth team.
I am a sexual abuse survivor, there may be special emotional
issues that may present during labor and delivery that I am
not prepared for. I have been diagnosed with Post Traumatic
Stress Disorder and anxiety, and am prone to panic attacks.
Being aware of this, I have been working with a therapist, trained
in hypnosis, on calming and self-soothing (hypno-birthing) for
the last trimester. I have also taken Lamaze classes, practiced
prenatal yoga, walked several miles per day, and generally prepared
for birth in every way possible.
are our optimal choices for birth.
First Stage (Labor):
· Would prefer my own clothes.
· Would prefer to keep medical staff to a minimum.
· Would prefer to keep vaginal exams to a minimum.
· Maintain mobility (Walking, rocking, up to bathroom,
· Clear fluids and ice chips.
· Positioning as desired.
· Heparin lock, if needed.
· Intermittent Monitoring (ACOG Standards) with EFM.
do not offer me pain medications, I will ask for them if I want
them. These may include: IV Demerol or ultra low dose epidural
(walking epidural) unless medically impossible.
o Breathing, Focusing, etc
o Water: would like to use the birthing tub and/or shower
o Heat or Cold packs.
o Massage (back, foot, counter pressure, etc.).
I would like to be able to move around and change position
at will throughout labor. I would like to be allowed to choose
the position in which I give birth, including squatting or on
my hands and knees.
Birthing Tub: I am aware that _____ hospital has a birthing
tub and birth balls, which I would like to use.
IV: I would prefer not to have an IV. If necessary, I
will accept having a heparin lock in place.
External Fetal Monitoring: We expect that you will need
to monitor me upon arrival, but we request that monitoring be
Prep: I would prefer to avoid an enema or extensive shaving
of pubic hair.
Artificial Rupture of Membranes: I do not wish to have
the amniotic membrane ruptured artificially before the birth
unless signs of fetal distress require an internal monitor.
Induction: I would prefer to use natural methods to start
Anesthesia and Pitocin: I do not wish to use any anesthesia
unless I request it during labor. I do not want routine Pitocin
to induce or augment labor or after the birth. Please allow
us to try natural induction methods, and to breastfeed immediately
to avoid any chance of hemorrhage.
· Choice of position
· Spontaneous Bearing Down
· Birth/Squat Bar
· I would rather tear than have an episiotomy, but please
use compresses, massage and positioning.
I do not wish an episiotomy unless required to avoid an
extensive tear. I would prefer a medium-sized tear to an episiotomy.
· Delay the cord cutting until it has stopped pulsing
so the baby can receive all the placental blood
· Prefer husband Rob to cut the cord.
· Delay the eye medication
· Breastfeeding only, and within ½ hour of delivery
· No pacifiers or glucose water (to avoid nipple confusion)
· No separation of Mother & Baby
Birth: I would like to be allowed to hold the child immediately
after birth, skin-to-skin. We would prefer that the cord not
be cut immediately, but given a few minutes to cease functioning
Breastfeeding: I intend to breastfeed and do not wish
to have any bottles given, including glucose water.
Rooming-in: We would like to have the baby remain with
us in our room after birth. This is very important to us. **
We do not want the baby to be taken away from us unless she
requires medical treatment, or unless we request to have
her taken to the nursery. We would like to have the baby examined
in our presence.
Corrective Lenses: I need to wear contact lenses or glasses
at all times when conscious. I wear extended wear contact lenses,
and my husband will have my glasses in case I need to remove
Cesarean Birth: I wish to have an epidural for anesthesia,
and to have my husband and doula present for the birth, if possible.
The child, if she is not in distress, should be given to my
Partner and Doula present
Partner to cut the cord
Breast feeding in recovery room
Breast feeding as soon as possible
Unlimited visitation for parents
Handling the baby (Kangaroo care, holding, care of, etc.)
If the baby is transported to another facility, move
us as soon as possible