Birth Plan Template
Birth Plan Template
Guide & Checklist
A birth plan is a document that outlines your preferences for labor and delivery, including details such as where you plan to give birth, who you want on your medical team, and pain relief options.
What to Include in Your Birth Plan Template
Include details such as any specific medical conditions, allergies, or previous birth experiences. Also include information about what should happen in unexpected complications.
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Personal Information
Provide essential details to avoid confusion.
- • Full name & DOB
- • Contact (Phone/Email)
- • Healthcare provider name
- • Partner’s contact details
- • Medical history / Allergies
- • Hospital or birth center name
Labour Preferences
- • Labor at home as long as possible
- • Use of pain relief medications
- • Monitoring methods for baby’s heartbeat
- • Positions (walking, ball, bath)
- • Ambiance (dim lighting, music)
Delivery Preferences
- • Desired position (squatting, side, stool)
- • Who should be present
- • Partner cutting umbilical cord
- • Delayed cord clamping
- • Immediate skin-to-skin contact
- • Natural or waterbirth preference
Pain Management
- • Natural techniques (breathing, massage)
- • Openness to medication
- • Avoidance of certain meds
- • Alternative methods (acupuncture)
- • Birthing tools (TENS, ball)
- • Epidural / Nitrous oxide preferences
Interventions
State your preferences regarding medical interventions.
- • Episiotomies, forceps, vacuum preferences
- • Avoidance unless necessary
- • Consultation before intervention
- • Use of pitocin
Newborn Care
- • Delayed cord clamping
- • Immediate skin-to-skin
- • Feeding plans (breast/formula)
- • Delay routine procedures
- • Rooming in with baby
Postpartum Preferences
- • Timing for breastfeeding
- • Limiting visitors
- • Postpartum support (lactation consultant)
- • Pain management
- • Dietary preferences
Emergency Situations
- • C-section preferences
- • Anesthesia preferences
- • Partner presence in OR
- • Informed consent
Additional Requests
- • Cultural/Religious preferences
- • Provider gender preference
- • Use of comfort items (favorite pillow)
- • Environmental (quiet room)
Signatures
“Remember to be flexible and open to changes.”
Frequently Asked Questions
Can a birth plan be handwritten?
Yes, it can be handwritten. The most important thing is that it is clear and easy to understand.
When do you start making a birth plan?
It’s generally recommended to start during your second trimester, around 28-30 weeks.
What is the golden hour after birth?
The first hour immediately following birth—crucial for bonding and breastfeeding.
What can you refuse during labor?
You have the right to refuse procedures like epidural, episiotomy, or routine IV fluids unless medically necessary.