Sample Birth Plan
This is an example of a natural hospital birth plan. This is meant only as a sample, for you to get the feel for what a birth plan might look like.
You will want to draft and customize your own birth plan based upon your wishes. If you are unsure of your wishes, I recommend doing lots of your own research and sitting down with a doula or other birth professional.
Our Birth Plan
Jane and John Doe
Due Date: August 09, 2011
Birth Facility: Morgan County Hospital
Doctor: Dr. McGregor
Pediatrician: Dr. Pennington
This is our first child, and we are looking forward to a natural birth experience. We have taken independent childbirth classes and have read as much as possible to prepare ourselves for the birth. We have hired a doula to be present for our birth.
The birthing environment is very important to us. For this reason, we would like to keep the labor room peaceful and quiet, with the lights dimmed, the door closed, and as few strangers and visitors as possible (no residents please). The mother would like to wear her own nightgown while in labor. Other than our doula, the mother's sister and mother may be present.
Our doula will help with pain management. The mother plans to handle any pain during labor in the following ways:
– Walking, Swaying, Changing Positions
– Music / Relaxation CD’s
– Water (shower, tub)
– Breathing / Vocal Tones
– Heating Pad
Please do not offer an epidural or pain medication to the mother; She will ask for it if she feels that she needs something more.
Medications / Procedures
The mother would like to remain upright as much as possible during labor. We request intermittent fetal monitoring or a telemetry fetal monitor if one is available.
The mother wishes to avoid medications and added procedures when possible. We understand that in some cases, certain interventions are necessary, but would like to discuss all options with our doctor and request the right to accept or deny any interventions unless it is an emergency.
We request that an IV only be placed if necessary. We request that no episiotomy be performed and that the mother is allowed to tear naturally. The mother would like to avoid a catheter and instead be allowed to use the restroom throughout labor.
If induction seems necessary, we would like time to try some natural induction methods before using medical induction.
If a cesarean section seems necessary, we would like to obtain a second opinion from another doctor.
If a cesarean section is needed, we would like:
– The father to be present (and the doula if possible.)
– The mother to remain awake.
– The mother be allowed to see her baby immediately upon delivery.
– The mother be allowed to attempt breastfeeding as soon as possible.
We request that the baby is placed directly onto mom's chest and that any vital signs be taken from there unless there is an emergency. The mother would also like to breastfeed as soon as possible after the birth. We request that the placenta is delivered naturally unless the time elapsed becomes worrisome.
If it is necessary for the baby to be taken to the nursery, we ask that the father is allowed to stay with the baby at all times.
We would like to decline:
– the first bath (we will do this at home)
– eye drops
– any shots/vaccinations
– sugar water/supplementation
– pacifier / artificial nipples
If there are complications or procedures need to be done on our baby, we request that our pediatrician is contacted immediately so that we may discuss our options with him.
If the baby is a boy, he will NOT be undergoing a circumcision.
We would like to “room in” with baby and request access to a lactation consultant if needed.
A Special Thanks
We want to extend a special thanks to all who will help us in making this a joyous event.
Our doctor is aware of our birth plans and is in agreement with our wishes.
Doctor's Signature ____________________________________________
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