Birth Plan

(Last Name) Family Birth Plan

Mother:

Father:

Doula:

We understand that certain emergency or other medical circumstances may not

allow for the accommodation of the goals listed below.
Home Labor Goals

 We would like to labor at home as long as possible, with our doula present,
before going to the hospital.

Hospital Labor Goals

 We plan to have present at the birth and/or labor:
 We ask that all other visitors and unnecessary staff be turned away until we
(mom and dad) have had time alone with our new baby.
 I prefer not to have catheter unless determined to be required for another
procedure to facilitate delivery.
 The birth environment is important to us. We ask that lights be kept dim,
noise be kept to a minimum, be able to play soothing music, door kept closed for
privacy.
 I would like to wear my own clothing, although the staff may offer a hospital
gown.
 I would like the opportunity to be up out of bed as much as possible during
labor.
 I would like the option to eat when desired.
 I prefer a monitoring method that allows me to remain mobile.

Birth Goals
 We are attempting to have a natural, unmedicated birth without unnecessary
medical intervention.
 We understand that there are procedures which may become necessary.
 Except in the case of an emergency, we ask that we be given the opportunity
to accept or refuse any procedure or medication.
 We request that the least invasive or restricting versions of procedures be
used.

Induction (if necessary)

 We ask that non-chemical induction methods be tried first: walking, breast
stimulation, sexual intercourse.
Pain Management Goals
 We plan to handle pain with relaxation, massage, fitness ball, changing
positions, walking breathing, and/or water (shower or tub).

Delivery Goals
 I would like to push at my own pace (Mother-Directed Pushing).
 I prefer not to have an episiotomy unless determined to be medically
necessary. I would first like to try perinea massage, support and warm
compresses.
 If labor or delivery seems stalled, we would like the opportunity to try different
positions (hands and knees, squatting, birth stools, etc.)
 We would like to have the baby placed on the mother’s chest with skin-to-skin
contact immediately after the birth and for the first 1 to 2 hours following the
birth.
 We would like to try to have the baby breastfeed as soon as possible.
 We would like the staff to help the mother change position if necessary to
facilitate breastfeeding.

Umbilical Cord
 Please do not cut the cord immediately. We would like to delay a bit after
birth before this is done.
 Please offer the father the opportunity to cut the cord.

Newborn Care Goals

 We would like to be present at the baby’s first bath.

Circumcision (if boy)

 We would like at least one parent to be present at the circumcision.

Cesarean Section (if medically necessary)

 I would like to be conscious
 We would prefer that our baby breastfeed immediately or as soon as possible
afterward in the recovery room.
 We prefer the baby and father remain in the recovery room with the mother.

Birth Recovery Goals

 We prefer to have a private room, if available, and that the father and baby be
allowed to room-in.
Breastfeeding Goals
 We would like to establish breastfeeding. please do not offer any bottles to
the baby without parental notification of a medical need.
 We would like to meet with a lactation consultant before leaving the hospital
to have techniques checked.

Thank you for taking the time to help us achieve a natural childbirth for our baby!