Birth Plan Template

The main purpose of a “birth plan,” also called “birth preferences,” is to let us know who you are, and what your ideal birth would be like. A few paragraphs or “bullets” should be enough, and then it can get discussed further at your prenatal visits.

  • We would like to know your style for coping. Do you like lots of verbal encouragement or not much? Are you an “explanations” type of person or a “just tell me what to do”? Are you an “unmedicated no matter what” or an “epidural as soon as possible” or somewhere in between? How vigorously would you like us to try to dissuade you from medication if you ask for it? Do you want the midwife by your side as much as possible, or would you prefer to spend much of your labor privately with your partner, knowing your midwife is nearby?
  • What, if anything, do you think will make the birth more special for you? Our general practice is to keep the lights fairly low, voices calm and quiet, non directive as far as positions, no routine episiotomies, and the baby placed on mom immediately at birth, unless medically necessary to go to pediatrics. Do you or your partner want to help receive the baby into your hands? Is there a particular piece of music you’d like to hear? If you don’t know the baby’s gender, whom do you want to announce it?
  • Who will your birth companions be? Will they need special care? Are there people – family or friends – who wish to be present, but in whose presence you would not feel comfortable? You are the most important person in this endeavor, and your physical and psychological well being is paramount.
  • Newborn care: circumcision, eye care, type of feeding, rooming in (which we encourage)
  • Early discharge?

Your Birth Preferences help us to know you, so we can best support you at a time when you may not feel like talking and telling us these things. We want you to feel confident that even in a large group practice, the midwife attending you will know something about you, which is as important to your care as all our midwifery expertise.

Some basic MAMA facts to keep in mind:

  • We keep cervical exams to a minimum, doing them only if they will affect our management;
  • We do not perform routine episiotomies;
  • Comfort measures include hydrotherapy, birth ball/stool, massage;
  • We do not require routine IV access, except in the case of VBAC (vaginal birth after cesarean);
  • For the majority of our clients, we can use intermittent fetal monitoring. Some exceptions include VBAC candidates, women using pain medication, inductions, if there is a fetal heart rate abnormality, or certain complications of pregnancy;
  • We are a teaching hospital and may ask if you would be willing to have a student involved in your labor and birth. We encourage you to consider participating.

Persons at birth
Partner _____________________________ Doula __________________________________
Other support person(s) _______________________________________________________

Pertinent History
Specific fears/concerns, health history, labor or birth history that might help us to better support you in labor __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Medication
Certain wants unmedicated _____________________________________________________
Open _____________________________________________________________________
Certain wants epidural/narcotics _________________________________________________

Verbal Coaching
Everything explained with reasons ________________________________________________
Supportive language, no need for detailed explanations _________________________________
Likes direction, prefers need to know basis _________________________________________

Partner Involvement
Assisting with birth ____________________________________________________________
Cutting the cord ______________________________________________________________
Announcing sex of baby ________________________________________________________

Postpartum
Breastfeeding __________________________ Bottlefeeding ___________________________
Circumcision Yes __________ No __________ Maybe ___________
Early discharge Yes __________ No __________ Maybe ___________
Cord blood banking Yes __________ No __________

Newborn
Hepatitis B Vaccine ___________________________________________________________
Erythromycin eye ointment ______________________________________________________


** Please use this as an opportunity to share with us anything else about who you are and what you need (i.e., family traditions, birth plan wishes, dietary needs, spiritual, cultural or religious customs, etc.) _____________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________


Click here to download our template as a word document.
Read a sample birth plan here.

Read "A Letter to My Daughter" by Flavia Goncalves