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Sample Birthing Plan 1: Bullet Format
Mother-to-be: Jane Smith
Birth site: Family Birthing Center, Lawrence, KS
Labor support: Joe Smith, husband and father-to-be
Physician: Jon Doe, MD
My goal is to deliver my daughter as safely and naturally as possible without medical interventions unless the
benefits outweigh the risks. I plan to participate along with my husband and my care providers in making decisions
about my labor, delivery and postpartum care. Listed below are my birth preferences; I understand that final decisions
about my care will be discussed and agreed upon in the birthing room with my well-being and the safe delivery of my
baby as the most important considerations.
In case of a complication which requires emergency care, we ask that our care providers still do their best to accommodate as many of our preferences as possible. We would only want our baby to be born via Caesarean section in the
case of an absolute emergency.
Thank You
Sample Birthing Plans
Birth Preferences
Early labor and preparation:
• Wear my own clothing
• Prefer not to use an IV
Labor:
• Use of electronic fetal monitor externally only for an initial 20 minute strip; after that, I would prefer intermittent Doppler monitoring
• Want to move freely and be able to walk around out of bed/sit up
• Would like light foods and clear liquids, taken orally
• Allow membranes to rupture naturally, even when dilation nears 10 cm
• Allow labor to proceed on its own; prefer no artificial induction methods
• Would like shower/whirlpool, massage and soft music
• Prefer not to use medication
• Dimmed lighting
Delivery:
• Labor position: whatever feels most comfortable at the time
• No episiotomy unless absolutely necessary
• I’d like to push when I feel the urge (maybe not with each contraction)
• I would like my husband to “catch” baby with doctor assistance
• I would like my husband to cut the umbilical cord
Postpartum:
• Want baby in room at all times
• Bottle feeding
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Sample Birthing Plan 2: Paragraph Format
Our Birth Plan: Jane & Joe Smith
Physician: Jon Doe, MD
Hospital: Family Birthing Center - Lawrence, KS
My husband, Joe Smith, should be present with me throughout labor and delivery.
I need to wear contact lenses or glasses at all times when conscious, as my vision is bad. My contact lenses take very little
time to remove in the event of an emergency. My husband will have my glasses in case I need to remove my
lenses.
We do not wish to have continuous fetal monitoring unless the baby is in distress. I understand there will be a period of
external fetal monitoring upon arriving at the hospital, and afterwards monitoring will be intermittent as long as everything looks okay.
I would prefer to avoid an enema or extensive shaving of pubic hair.
I wish to be able to move around before labor and change positions at will throughout labor. I would like to be allowed
to choose the position in which I give birth, including squatting.
I would like an IV if I become dehydrated. I will accept having a heparin lock inserted into a vein so that an IV can be
started up quickly if needed.
I do not wish to have any membranes ruptured artificially before the birth unless it is absolutely necessary. I do not want
the internal monitor unless the baby has already shown some sign of distress.
I would like light foods and fluids by mouth throughout first stage of labor.
I do not wish an episiotomy unless absolutely required to avoid an extensive tear. I would prefer a medium-sized tear to
an episiotomy. I intend to take all possible measures to avoid the need for an episiotomy.
I want to hold the child immediately after birth. We would prefer that the cord is cut by my husband. If a Caesarean is
necessary, I wish to have an epidural for anesthesia, and to have my husband present. The child, if he is not in distress,
should be given to my husband.
I intend to breastfeed the infant and do not wish to have any bottles given to him, including glucose water.
We would like to have the baby remain in our room. We do not want the baby to be taken away from us unless he
requires medical treatment, or unless we request to have him taken to the nursery.
Sample Birthing Plans
I wish to use anesthesia during labor. I will want local anesthesia for repair of tears or of episiotomy. I prefer pitocin to be
used.
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Sample Birthing Plan 3: List Format
Names: Jane & Joe Smith
Physician: Jon Doe, MD
Hospital: Family Birthing Center - Lawrence, KS
LABOR:
Enema: None
Prep: None
Presence of family: Birthing partner present at all times.
Position for labor: Whatever works at the time.
Onset of labor: Spontaneous. If late or other complications, will discuss other options at the time.
Hydration/fluids: Drinking water until no longer tolerated, then ice chips.
Food: Light food until no longer tolerated.
Monitoring fetal heart: Stethoscope or Doptone.
Pain relief: Epidural.
Speed up labor: If necessary, walking, pelvic rocking. If complications, will discuss other options at the time.
To empty bladder: Walk to the bathroom.
BIRTH:
Position: Squatting. If that doesn’t work, try whatever works.
Expulsion techniques: Bearing down with contractions.
Bed for birth: Yes.
Care of perineum: Try for intact perineum with massage, support, and hot compresses.
Presence of family: Birthing partner present at all times.
Handling of baby: Mother gets to hold baby immediately, with birthing partner helping so baby doesn’t accidently get
dropped. Suctioning or whatever done while baby is in mother’s arms unless there are complications, then will discuss
other options at the time.
BABY CARE:
Airway: Suction.
Warmth: Baby skin-to-skin with mother, with blanket covering both.
Immediate care: Baby held by parents and nursed by mother. If parents need a break, baby is kept nearby in bassinet.
Eye care: Nonirritating agent as late as possible.
First feedings: Breastfeeding on demand.
Contact with baby: In room with parents.
Sample Birthing Plans
AFTER BIRTH:
Delivery of placenta: Spontaneous.
Cord cutting: Clamp and cut after it stops pulsating. Birthing partner cuts cord.
Presence of family: Birthing partner.
Discharge of mother and baby: As soon as possible. If medically feasible, within 24 hours of admission to enhance
insurance coverage.
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Sample Birthing Plan 3: List Format
BIRTH PLAN (PROBLEMS)
C-SECTION:
Rationale: Unless emergency prohibits, confirm fetal heartbeat indicators with fetal scalp blood oxygen readings.
Partner’s presence: Birthing partner present.
Anesthesia: As little as possible depending on circumstances. No general unless absolutely necessary.
Participation: Events explained as they occur.
Contact with baby: Held by birthing partner immediately after birth, where mother can touch and see. Breastfeeding
as soon as possible.
Discharge of mother and baby: As soon as possible.
SICK INFANT:
Contact with baby: Parents visit and care for baby as much as possible. If baby must be transferred to another hospital,
mother goes, too; if that’s not possible, birthing partner goes with baby.
Feeding: Mother nurses baby. If that’s not possible, parents feed mother’s expressed milk to baby. If neither is possible,
will discuss other options at the time.
Sample Birthing Plans