Birth Plan Template

All you need to create your birth plan instantly!

BIRTHSTORY.COM

HEIDI’S BIRTH PLANNING TOOL

So, you’ve read all the books, listened to every episode of my podcast-kidding not
kidding-, done your research, and you have an idea of what type of birth is ideal and
aligns with you. Or maybe there are so many options, you have no idea what you want!
Both scenarios are okay, and I am here to help. I’ll be honest, I have 3 birth plan
templates ready to go for all of my clients.

1. Spontaneous- Planned Medicated, Planned All-Natural, or Wait & See Attitude

2. Induced- Planned Medicated, Planned All-Natural, or Wait & See Attitude
3. Gentle Cesarean

I have created a birth planning tool for you with all three birth plan templates. The power
is in going through the exercise of the birth planning tool and hopefully, with your doula!
I want to help be a guide for you to think of some of the 574,000 questions you may not
know to think about. Be sure to research any terminology you are unfamiliar with, and if
there is a goal you would like to meet that your birth location does not offer, please do
not be afraid to speak up, plan and prepare for the birth that you want-no matter what
that looks like! You can easily copy and paste your preferred options using the template

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or get creative and put together a visual birth plan. Either way, having a birth plan can
help your birth team stay on the same page.

X OX O-

Your Virtual Doula Heidi

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Birth Plan Template
These are my birth wishes pending a healthy baby and a healthy me!

BIRTHSTORY.COM

Name & Preferred Pronouns:

DOB:

Allergies:

GBS status:

Baby # ?:

Provider and Birthing Location:

Religious Preference:

Special Diet:

Birth Environment
LABOR ENVIRONMENT: PLEASE SELECT YOUR
BIRTH PREFERENCES
1. I prefer a midwife to deliver
2. I would like a room with a bathtub and a shower
3. Please do not ask me question during a surge
4. I would like to not feel rushed
5. No students
6. No males
7. Please assign a nurse experienced in unmedicated deliveries
8. I would like Hypnobirthing/HypnoBabies language used
9. Music to be used on a bluetooth speaker or in my earphones
10. I would like to bypass triage if you can tell I am in active labor by my sounds and
surges
11. Free movement
12. A room with a birthing ball and peanut ball
13. Please keep conversations outside of the room including at shift change
14. I will eat and drink throughout labor as my body needs to
15. Please keep the lights dim or off
16. I would like to diffuse essential oils
17. Please help me to hang up my birthing affirmations
18. I would like my religion incorporated into my birth experience

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Pain Management
PAIN MANAGEMENT OPTIONS
1. I prefer an unmedicated birth
2. Please do not offer me pain medications
3. I would like the option to use Nitrous Oxide
4. I would like an epidural
5. I do not want an epidural
6. I would like to have a wait and see attitude about pain management options
7. I do not want IV pain medications
8. I am open to IV pain medications
9. I will be using Hypnobirthing/Hypnobabies for pain management

Stage 1
STAGE 1 OF LABOR: MEDICAL INTERVENTIONS AND
PROTOCOLS. SELECT ALL OF YOUR BIRTH
PREFERENCES.
1. Delayed IV hep lock port to delivery
2. Consent to hep lock port
3. I do not consent to IV hep lock port
4. I consent to limited vaginal exams
5. I do not consent to vaginal exams.
6. Natural rupture of water
7. Artificial rupture of water is OK if it helps me progress
8. If artificial rupture is suggested, I would like help to break my own water
9. No continuous monitoring
10. Intermittent monitoring is ok bedside
11. Intermittent monitoring is OK if portable and waterproof
12. I do not want bands used when monitoring
13. I decline all fetal monitoring
14. Bedside monitoring is OK with the bands
15. Do not intervene if labor naturally stalls
16. I would like medical support for labor to continue progressing including Pitocin
17. I would like natural support for labor progression including nipple stimulation,
herbs, and position changes
18. I do not consent membrane sweeping
19. I consent to membrane sweeping

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Stage 2
2ND STAGE OF LABOR: PLEASE SELECT YOUR BIRTH
PREFERENCES
1. No coached pushing, my body and the fetal ejection reflex will guide me
2. Yes, coach me during pushing! I would like help and guidance.
3. Maybe just coach me on pushing if I need but let my body try first
4. I'm open to nausea medication
5. Please help me naturally with nausea using essential oils, smelling salts, and
alcohol wipes
6. I am not open to nausea medication or assistance, just let me puke!
7. I will choose the position in which I give birth
8. I would like a water birth
9. I would like to catch my own baby
10. My partner would like to catch our baby
11. I would like my provider to catch my baby
12. Please stretch my perineum with a natural oil like mineral, coconut, or almond
13. Please use warm compresses on my perineum
14. I prefer to tear naturally
15. I prefer an episiotomy over natural tearing
16. I would like to use a birth mirror
17. I would like to use a squat bar

Stage 3
3RD STAGE OF LABOR. PLEASE SELECT YOUR BIRTH
PREFERENCES.
1. Natural delivery of the placenta
2. Please do not tug or pull on my cord to use traction to deliver the placenta
3. I would like a routine injection of Pitocin to prevent bleeding
4. I do not consent to a routine injection of Pitocin
5. Delayed Cord Clamping
6. Delayed Cord Clamping for 2 minutes
7. Delayed Cord Clamping for 5 minutes
8. Delayed Cord Clamping until it has stopped pulsating
9. I would like to cut the cord

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 10. My partner will cut the cord
11. My Doula will cut the cord
12. I would like the provider to cut the cord
13. Another specified individual will cut the cord
14. Please use fundal massage to prevent bleeding
15. I approve Cytotec to reduce bleeding
16. I prefer not to have Cytotec to reduce bleeding
17. Please discuss any tears with me before I consent to repairing
18. In the event of minimal tearing, I prefer to heal on my own without repair
19. If I had an unmedicated birth and require tear repairing, please use lidocaine
20. I would like a lotus birth
21. Please save placenta for encapsulation and/or going home with me

Newborn Preferences
NEWBORN CARE: PLEASE CHOOSE YOUR
PREFERENCES
1. Please place my baby directly on my chest
2. All checks to be performed on my chest
3. No wiping off the vernix, I will rub it in myself
4. No baby hatting which disrupts bonding by eliminating the key sense of smell
5. No diapering, I want to be skin to skin with my baby
6. I consent to oral vitamin K if available
7. I consent to the Vitamin K injection
8. I decline the use of Vitamin K
9. I consent to antibiotic eye ointment
10. I decline eye antibiotic ointment
11. I prefer for my baby to have their first bath in the hospital
12. No bathing!
13. I do not want to be separated from my baby, please perform all newborn checks in
the room
14. I consent to the Hepatitis B vaccination
15. I decline the Hepatitis B vaccination
16. Exclusive breastfeeding
17. Exclusive bottle feeding
18. No pacifiers
19. No swaddling
20. No formula
21. I plan to breastfeed and bottle feed my baby
22. I would like to consult with a Lactation Consultant as soon as possible
23. If supplementing is necessary, I would like to use donor milk and a SNS
24. If formula supplementing is necessary, I would like to supply my own brand of
formula
25. I do not consent to hospital circumcision
26. I would like hospital circumcision, please discuss Gomco, Mogen, and PlastiBell

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 so I may choose the method

In case of Induction
INDUCTION: PLEASE CHOOSE YOUR BIRTH
PREFERENCES
1. I prefer to not be induced before 42 weeks
2. I agree with ACOG that Macrosomia (big baby) is not a reason for induction
3. Delay IV port and IV during cervical ripening
4. I prefer to start my induction first thing in the morning after a full night's rest
5. I would like the option to use a sleep aid like Ambien, Unison, and/or Benadryl to
sleep overnight at the hospital
6. If Pitocin is used, I would like to turn it down and then off once I am laboring on
my own
7. I do not wish to have my water broken as an induction method
8. Please look at me in the eyes and verbally walk me through the Foley Bulb
induction as you place it
9. OTHER Please ask me!

In case of a Gentle Cesarean

GENTLE CESAREAN: PLEASE SELECT YOUR BIRTH
WISHES
A GEN T L E CE SA R E AN ( SO M E TI M ES CA LL ED A FA M IL Y- C EN T E R E D
B IR T H) IN CL UD E S M A N Y F EA T UR ES , BU T I TS O VE R A LL P UR PO SE IS TO
I N V O KE A P EA C EF UL , C AL M A T M OS PH ER E T HA T CL OS EL Y M I M I CS
W HA T H AP PE N S D UR IN G AN D I M M ED IA T E LY A F TE R A N AT U R A L
C H IL D B IR T H.

1. I expect for my doula to be present in the OR

2. I expect for my birth partner to be present in the OR
3. Please keep all conversations not about me or my birth to yourself
4. I would like a gentle, family centered cesarean
5. Please use a clear drape so I can watch the birth of my baby
6. Please place EKG leads on my back so I may still be skin to skin without
disruption
7. I would like to breastfeed in the OR
8. I would like the baby to be on my chest and my partner to help support the baby

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 9. I request delayed cord clamping for 2 minutes
10. I request delayed cord clamping for 5 minutes
11. I request delayed cord clamping until the cord has stopped pulsating
12. I request a lotus birth
13. When wheeled out of the OR, I would like my baby to remain skin to skin on me
14. All newborn exams to be performed on my chest while I am being repaired
15. I would like help with vaginal seeding
16. My partner will be taking photos and videos
17. I prefer a spinal block for anesthesia
18. Please do not give me extra drugs for relaxation or pain without discussing them
with me first. I would like to be fully present and as aware as possible for the
procedure.
19. Please save my placenta for encapsulation and/or going home with me
20. Mother-assisted cesarean
21. Other Please ask me!

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