Sample Birth Plan Template
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A birth plan is a written outline of what you would like to happen during labor and delivery. This plan lets your obstetrician–gynecologist (ob-gyn) know your wishes for your labor and delivery.
Go over your plan with your ob-gyn well before your due date. But keep in mind that having a birth plan does not guarantee that your labor and delivery will go according to that plan. Unexpected things can happen.
Remember that you and your ob-gyn have a common goal: the safest possible delivery for you and your baby. A birth plan is a great starting point, but you should be prepared for changes as the situation dictates.
Name of your ob-gyn:
Name of your baby's doctor:
Type of childbirth preparation:
Choose as many as you wish:
[ ] I would like to be able to move around as I wish during labor.
[ ] I would like to be able to drink fluids during labor.
[ ] An intravenous (IV) line for fluids and medications
[ ] A heparin or saline lock (this device provides access to a vein but is not hooked up to a fluid bag)
[ ] I don't have a preference
I would like the following people with me during labor (check hospital or birth center policy on the number of people who can be in the room):
It's OK [ ] /not OK [ ] for people in training (such as medical students or residents) to be present during labor and delivery.
I would like to try the following options if they are available (choose as many as you wish):
[ ] A birthing ball
[ ] A birthing stool
[ ] A birthing chair
[ ] A squat bar
[ ] A warm shower or bath during labor. I understand that a bath would be used only for the first stage of labor, not during delivery.
[ ] I do not want anesthesia offered to me during labor unless I specifically request it.
[ ] I would like anesthesia. Please discuss the options with me.
[ ] I do not know whether I want anesthesia. Please discuss the options with me.
I would like the following people with me during delivery (check hospital or birth center policy):
[ ] I prefer to avoid an episiotomy unless it is necessary.
[ ] I have made prior arrangements for storing umbilical cord blood.
For a vaginal birth, I would like (choose as many as you wish):
[ ] To use a mirror to see the baby's birth
[ ] For my labor partner to help support me during the pushing stage
[ ] For the room to be as quiet as possible
[ ] For one of my support people to cut the umbilical cord
[ ] For the lights to be dimmed
[ ] To be able to have one of my support people take a video or pictures of the birth. (Note: Some hospitals have policies that prohibit videotaping or taking pictures. Also, if it is allowed, the photographer needs to be positioned in a way that does not interfere with medical care.)
[ ] For my baby to be put directly onto my chest immediately after delivery
[ ] To begin breastfeeding my baby as soon as possible after birth
In the event of a cesarean delivery, I would like the following person to be present with me:
[ ] I would like to see my baby before my baby is given eye drops.
[ ] I would like one of my support people to hold the baby after delivery if I am not able to.
[ ] I would like one of my support people to go with my baby to the nursery.
[ ] I would like my support person to know what shots my newborn will receive.
Baby Care Plan
Feeding the Baby
I would like to (check one):
[ ] Breastfeed exclusively
[ ] Bottle-feed
[ ] Combine breastfeeding and bottle-feeding
It's OK to offer my baby (check as many as you wish):
[ ] A pacifier
[ ] Sugar water
[ ] Formula
[ ] None of the above
Nursery and Rooming-In
If available at my hospital or birth center, I would like my baby to stay (check one):
[ ] In my room with me at all times
[ ] In my room with me except when I am asleep
[ ] In the nursery but be brought to me for feedings
[ ] I don't know yet. I will decide after the birth.
[ ] If my baby is a boy, I would like him circumcised at the hospital or birth center.
Last updated: August 2022
Last reviewed: January 2021
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This information is designed as an educational aid for the public. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer.