Sample Birth Plan Five
At the top is listed the name of the family, the hospital and the 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: Midwife Name, Father Name, Doula Name.
- We ask that all other visitors and unnecessary staff be turned away until we (the parents) have had time alone with our new baby.
- The mother prefers not to have an IV administered unless determined to be required for another procedure to facilitate delivery.
- The mother prefers not to have a 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, the door be kept closed for privacy.
- We will bring our own music.
- The mother may wish to wear her own clothing, although the staff may offer her a hospital gown.
- The mother would like the opportunity to be up out of bed as much as possible during labor, depending on her needs.
- We are attempting to have a natural, un-medicated birth without unnecessary medical or chemical 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 and water (shower or tub).
- Please do not offer chemical pain relief.
- The mother would like to push at he own pace (Mother-Directed Pushing).
- The mother prefers not to have an episiotomy unless determined to be medically necessary. She would first like to try perineal 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.
- We would like the father and the doula to be allowed to take photos or video tape parts of the labor and birth.
- Please offer the father the opportunity to cut the cord.
Newborn Care Goals
- Please delay the eye medication and vitamin K shot until we have spent some time with the baby, preferably as long as possible before leaving the labor and delivery room.
- We would like to be present at the baby's first bath.
- We would like to have a set of footprints stamped into our scrapbook when footprints are done.
Circumcision (if boy)
- We would like at least one parent to be present at the circumcision.
Cesarean Section (if necessary)
- The mother would like to be conscious
- The mother would like the father present if he is willing.
- 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.
- We prefer that our stay at the hospital be extended to the longest our insurance will allow so that the mother may recover as fully as possible before returning home.
- If not rooming-in, we would like the baby brought to the mother to meet it's on-demand feeding needs.
- We would like to establish breastfeeding. Please do not offer any bottles to the baby without parents' 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 first baby!