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Birth Plan Template


Birth Plan Example

Pateint Name DOB:

*Present during labor and birth: Spouse , _________ & Doula , _________

We have prepared for a natural VBAC, and have chosen our provider and North Fulton Hospital carefully. We understand that events in labor can occur and we are flexible. The overall health of mom and baby are our first concern, we wish to be kept informed and involved in deviations from our birth plan.

I would prefer the following:


-dim lighting, quiet and calm environment, and to wear my own clothing
-to move, change positions or locations (bed, chair, birth ball, etc) as is comfortable to me -NOT be offered pharmacological pain management or an epidural
-limited cervical checks
-to maintain hydration orally, and have light snacks (hep lock/saline lock IV)
-to follow my body’s pushing cue’s, and to try various pushing positions
-please discuss any need for an episiotomy or instrument assistance before performing either

After Delivery

-place baby to my chest/belly for immediate skin-to-skin, we would like an undisturbed “first hour” -delay cord clamping until pulsations cease
-for the placenta to deliver naturally, please no tugging

Baby Care

-NO eye ointment/drops
-NO Hepatitis B vaccine
-vitamin K injection ok after ‘first hour’
-delay bath at least 24 hrs (perhaps longer, we really see no rush)
-exclusive breastfeeding (no pacifiers, formula, sugar water, etc)
-baby to stay in room with parents, all procedures/tests done in mothers room

Cesarean Delivery – in the event of a cesarean, we wish to have and ‘family-centered’ cesarean
-spouse and doula present
-I would like the drape dropped during delivery of baby
-baby to be placed on my chest for immediate skin-to-skin, and to stay there for the remainder of surgery -baby to remain with me in recovery room
-baby care as outlined above

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