Birth Plan Sample

A sample birth plan to use as a guide for your labor and birth.

Jan 5, 2007 Brenda Lane

A sample birth plan can be used as a starting point for parents when writing their own birth plan.

Are your struggling with how to write your birth plan? Many parents find it helpful to have a place to start for writing a birth plan. Below is a sample to guide you.

Birth Plan

John and Susan Brown - Due date June 30, 2007

General Hospital

Physicians: Drs. Smith and Lee

Doula: Jane Wright

Overview

We desire a labor and delivery that is as free from medication and other medical interventions as possible. We strongly prefer a vaginal delivery instead of a cesarean. Please discuss any suggested interventions or procedures with all of us and obtain our verbal consent before initiating any such interventions or procedures.

First Stage Labor

  • FHR monitored by intermittent monitoring or telemetry (portable); no internal motniros please
  • Vaginal exams only upon consent; as few and as gently as possible
  • No augmentation of labor such as pitocin, amniotomy, or stripping of membranes unless non-medical techniques for augmentation of labor are not effective
  • Husband and doula are to be present at all times
  • No analgesia/anesthesia unless we ask for it
  • Freedom to move/walk around during labor
  • Freedom to eat and drink during labor as needed
  • Heparin lock for IV
  • Please avoid use of urinary catheter unless anesthesia is used and consent given

Second Stage Labor

  • Choice of positions for pushing - no stirrups for birth please
  • Prolonged length of second stage if progress is being made
  • Spontaneous bearing down
  • Would like to labor down until urge to push is felt
  • We would prefer to tear rather than have an episiotomy – use of compresses, massage, coaching for slow birth of baby’s head and positioning other than lying down with stirrups to avoid need for episiotomy
  • If assistance is delivery is needed, please use suction rather than forceps

After Birth

  • Baby to breastfeed immediately; please delay newborn procedures until baby has had the opportunity to breastfeed on both sides
  • Natural delivery of placenta
  • No post-delivery pitocin or pulling on the cord please
  • If stitching of perineum is necessary, please use local anesthetic
  • Delay cord cutting
  • Newborn to stay with parents at all times
  • Please perform all physical exams and procedures in room with mother
  • Breastfeeding only: no bottles, pacifiers, artificial nipples, formula, or water
  • No circumcision please

For more information about what to include, see Birth Plan.

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Comments

Dec 29, 2008 8:12 AM
Guest :
Bring 4 copies with you to the hospital:
- Nursery
- Nurse(s)
- Birthing Room
- Extra copy for the doctor (This is especially important if your reg OB is not on call.)

Be sure to give your OB a copy of the birth plan well in advance of due date so that it can be approved and so it can be discussed between you and your OB.
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