Here’s an example birth plan for you to adapt to your preferences. Remember to keep all birth plans to one page. This example birth plan has a second page to be used in case of C-section. Example Birth Plan.
Mama’s Example Birth PlanMom and Dad’s name, Baby’s Name, Estimated Due Date (EDD)
Doctor’s name and the hospital:
Giving birth is a team effort, and we are so grateful to have you on our team! Please accept our appreciation for your help and support in advance! I appreciate your gracious understanding of our autonomous choices, even if I choose to act “Against Medical Advice” and sign a liability waiver. I request for my partner, my doula, or my legal counsel to remain with me at all times throughout my birth.
During labor, we would like:
Food and drink as desired
A telemetry EFM unit
Two-handed vaginal exams
Minimal vaginal exams
During labor, we would like to avoid:
Routine IV fluids
Continuous electronic fetal monitoring
Any references to “moving things along”, “pain”, “hurt”, “tired”, or “hard labor”
Suggestions of anesthetics or analgesics
Artificial rupture of membranes
During birth, we would like:
Freedom to push in any position
To use warm compresses, lubrication, and perineal support to help prevent tears
To tear naturally instead of being pressured into an episiotomy
During birth, we would like to avoid:
Loud coaching or counting during pushing
Pushing while lying supine
Any episiotomy, vacuum, or forceps
Following birth, we would like:
Baby placed on Mother’s abdomen immediately
Cord to remain unclamped until empty
To keep the placenta
Delay bath, weight, measurements (“The Golden Hour”)
To breastfeed exclusively (no artificial nipples)
To meet with a CLC as soon as possible.
Following birth, we would like to avoid:
Early cord clamping and/or cutting
Traction on the cord to deliver the placenta
Wiping or rubbing off the vernix
Pitocin to birth the placenta
Hepatitis B vaccine
Vitamin K shot
Newborn eye antibiotics
The following issues are very important to us:
Without prior consent, we do not consent to an episiotomy; it is our choice to tear naturally. Without prior consent, we do not consent to clamping the cord until the cord is white, thin, and empty; all newborn procedures (even neonatal suctioning, administering oxygen, or other procedures) can be done on Mother’s abdomen/thigh or on the hospital bed while the cord remains unclamped and uncut. Without prior consent, we do not consent to any wiping of the vernix; we will gently rub in the vernix or ask for a clean cloth to wipe it off ourselves. I do not consent to any medical treatment without the presence of my spouse, my doula, or my legal counsel.
Mama’s Example Birth Plan for Caesarean DeliveryMom and Dad’s name, Baby’s Name , Estimated Due Date (EDD)
Doctor’s name and the hospital
I would like to obtain a second opinion if my physician recommends a c-section.
I do not consent to any medical treatment without the presence of my spouse, my doula, or my legal counsel.During the prep, I would like:
To have my doula remain at my side for my emotional support
All conversation between staff be kept to a minimum
To have the drape placed below my breasts
I do not consent to tying down my arms unless I am unable to control them
I do not consent to tranquilizers, sedatives, or amnesiac drugs
During the birth, I would like:
Only necessary staff present
My doula to take photos
My husband to announce the baby’s gender after birth
To delay the cord clamping until the cord is empty
To have the baby be placed skin-to-skin on my bare chest and covered with heated blankets for warmth
The placenta to be kept for me to take home
During the repair, I would like:
To keep the baby skin-to-skin on my chest instead of using a warmer
To delay all newborn procedures
To keep the vernix on my baby’s skin so that I can rub it in myself.
My husband to cut the cord.
I do not consent to a single-layered suture to close my uterus; a double-layered suture must be used.
I do not consent to staples; I want a sutured closure of the skin
In recovery, I would like:
To see a certified lactation counselor as soon as possible.
To have daily visits from the CLC.
To keep the baby with me at all times.
To delay the baby’s bath, weight, and other measurements until after “The Golden Hour”