Birth Plan

BIRTH PLAN

I, {Name}, giving birth to my {number} child on or around {due date} (or: having labor induced on {date}), declare the following birth plan to be my direct wishes for the duration and follow-up of the procedure. I hereby request that my {doctor/midwife/doula}, {Name(s)}, and/or any other medical personnel who assist with the birth consider the following to be morally and legally binding, and that they follow this plan to the best of their ability.

Initial Stages

• I plan to give birth {at home/in a hospital, etc.}
• I plan on delivering {vaginally, C-Section, water birth, etc.}
• I have the following medical conditions/allergies: {List}
• I require the following medication: {medications, intervals}

Environment

• I would like the following people present for the birth: {partner, family members, friends, children, doula, etc.}
• I want only my {doctor/midwife} present unless medically necessary
• I would like {type of music} playing during the birth
• I would like {candles, dim lights, etc.}
• I would like someone to keep me hydrated with ice chips
• I would like {Name} to film/photograph the birth

Comfort/Pain Management

• I would like an enema
• I would like my pubic hair shaved
• I would like a urinary catheter
• I would like an IV to prevent dehydration
• I would like warm compresses
• I would like massages
• I would like hypnosis for the pain
• I would like perineal massages
• I would like an epidural at {times/frequency}
• I would like an episiotomy in the event of {condition(s)}

Delivery

• I would like to receive labor augmentation in the form of {form}, but only if {condition}
• I would like to induce labor if {condition}
• If a C-Section is recommended, I would like to {go to the hospital, get a second opinion, etc.}
• If something goes wrong with the labor or the baby, I would like to {emergency steps}

• I would prefer to {walk/stand/lie down} during labor
• I would prefer to {squat/lie down/use a tub/etc.} during delivery
• I {would/would not} not like to feel/see the baby crowning
• I {would/would not} like to help catch the baby
• During delivery, I would like to avoid: {Things to avoid}
• During delivery, I would like to ensure: {Things to do}

Post-Partum

• I would like to cut the cord
• I would like my partner to cut the cord
• I would like to bathe my baby
• I would like to breastfeed the baby {during/after} {time}

I understand that my desires and needs during the birthing process may be subject to change, and all requirements above should not be considered over my requests during the birth. Should I be incapacitated or unable to answer questions, please use this document as the primary reference.

IN WITNESS WHEREOF, the party has signed this Agreement as of the date first set forth above.

_______________________________
{Name}

_______________________________
Date

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