Sample Birth Plan

Name/Care Provider/Etc

To our birth team:  My husband and I understand that birth can go differently than planned and that decisions may need to be made during the process.  We intend to work with everyone present to make good decisions if need arises.  The following items are our preferences if the birth goes smoothly –as we expect it to go.  Our goal is to deliver our baby as safely and normally as possible without medical interventions unless the benefits outweigh the risks.  It is our belief that birth is a normal process; not a medical emergency and proceeds in the safest manner without interventions.

Here are some guidelines that describe the birth experience we desire.  Please do not deviate from this plan without our consent.  In case a decision about a medical procedure may be made when I am unconscious, I grant authority for making that decision to my husband. 

The concept of fully informed consent is critical to us.  We have prepared ourselves by taking an evidence based childbirth class and hiring a birth doula to assist us.

First Stage Labor:

• We would like to labor in a relaxed environment.  Please limit bright lights, loud voices, and unnecessary traffic in the room.  
• Labor Support:  We have chosen to use _________, a certified doula with ___________ as our labor support.   We request that she stay by my side for all procedures, even in emergency.
• IV’s:  Hep lock only.  No routine IV fluids.
• Electronic Fetal Monitors:  As we plan to move as much as possible during active labor for optimal fetal positioning, I request intermittent fetal monitoring except in case of severe fetal distress as recommended by ACOG standards.
• Vaginal Exams:  I would like the minimal required for you to assess my progress.  If my membranes have ruptured, I would prefer to avoid vaginal exams unless by my request. 
• AROM:  No artificial rupturing of membranes without my permission
• Labor Progress:  I prefer to try natural methods to promote dilation, such as walking, positioning, acupressure, and nipple stimulation, rather than medical interventions.  We do not want to be hurried unless signs show our baby is in trouble. 
• Pain Management:  I am having a normal birth.  Please do not offer me any pain-relieving medication. 
• Freedom of Movement:  Movement is important to me as it is significant to my pain management.  Unless there is a serious contraindication, I don’t wish to be still or lie in bed. 

Second Stage Labor: 

• Position:  If I must labor in bed, I wish to use the hospital birth bar to facilitate a squatting position.  My doula can assist me in using the birth bar.  We would like to be given the option of pushing while standing, squatting, or on hands and knees until I’m requested to be in bed.
• Mirror:  We would like to have a mirror positioned so I can see my progress.
• Pushing:  We have faith that my body knows instinctively how to push.  I do not want directed pushing until the baby’s head is crowning.  Then I would like my birth team to guide my in gentle pushing to allow my perineum to expand.  I request that the doctor or nurse massage my perineum before and during crowning to reduce the possibility of tearing.
• Perineum:  I wish to keep my perineum intact; however if it comes down to a choice, I would prefer to tear rather than have a surgical cut.

Third Stage:

• Umbilical Cord:  We choose to wait to clamp and cut the umbilical cord until after it stops pulsing.  My husband will cut the cord. 
• Skin-to-skin:  We wish immediate skin-to-skin contact on my chest. 
• Initial exam:  We wish the baby to be examined in my arms.
• Placenta:  We would like to wait for the placenta to detach without pulling or forcing.  If the placenta seems retained, I wish to breastfeed to encourage the uterus to contract.  I would like to see the placenta before it is discarded. 
• Pitocin:  I decline third stage pitocin unless there is significant bleeding that indicates hemorrhage. 
• Newborn procedures:  We would like to delay eye ointment, bath, foot-printing until we have had time to bond and breastfeed.  We decline the Hepatitis B shot.  Vitamin K shot?  (may depend on difficulty of labor or plan to circumcise) 
• Breastfeeding:  My plan is to breastfeed as soon as possible.  The baby should not be given anything by artificial nipples.  No pacifiers.  If blood sugar level becomes a concern, more frequent nursing will be encouraged as colostrum provides a more healthy and stable blood sugar than processed glucose.
• Rooming-in:  Our baby will stay in our presence at all times from the moment of birth until we leave the hospital unless in emergency situations.
• Circumcision:  none (do not retract foreskin), at hospital, or delayed

Emergency Cesarean

• It is my strong wish to give birth vaginally.  If my primary care provider determines that a ceserean is indicated, I would like the option to obtain a second opinion from another physician or a midwife if time allows. 
• My husband will accompany me.  I also request my doula accompany me.  
• Following a cesarean, if the baby’s condition permits, we would like the baby to be given directly to my husband.  He will stay with the baby until I am released from recovery.  My doula will accompany me to recovery.

Signatures