It is a good idea to keep your birth plan brief and concise.  The staff nurses in the hospitals are often very busy and don’t have time to read a wordy birth plan.  The sample below is a general plan for natural birth. Some of these requests are automatically done in some hospitals and are not in others. Take several copies of your birth plan to the hospital with you and be sure to give one to your doula.
   Sample Birth Plans:
 

_________________Family Birth Plan Our ideal plan is to have a natural childbirth. We are aware that complications can arise and we are willing to discuss any interventions that the hospital staff believe are necessary. Our requests:

1) Please do not offer any medication to us during labor unless an emergency arises and after we've discussed our options. The mother will request them if she decides to use them.

2) The mother would like to be able to move around freely during all stages of labor, if she wishes.

3) Intermittent electronic fetal monitoring with no continuous EFM unless medically warranted.

4) The mother would like to be able to drink fluids and eat as desired as long as no complications arise.

5) The labor will not be accelerated or augmented by artificially rupturing the membranes or using drugs.

6) Minimal number of vaginal exams.

7) Episiotomy to be avoided by perineal massage, hot compresses and slow delivery.

8) The father would like to cut the cord after it has stopped pulsating.

9) Baby to be placed on the mother immediately after birth and to remain there until mother relinquishes him or her.

10) If possible, please delay performing routine procedures such as administering the eye drops, vitamin K, etc. All newborn assessments to be done while baby is with the mother.

11) Please do not give the baby any bottles or IV, mother would like to begin breast feeding immediately.

12) In the advent the baby is a boy we do not wish to have him circumcised.

C-section Plan:

1) The mother would like our doula to be present in the OR along with the father. We would prefer to use Duramorph rather than morphine.

2) The mother would like the baby to come to her immediately in recovery.

3) If the baby is sick, the mother would like to be with the baby as much as possible.

4) The mother will breast feed and does not want a bottle, pacifier, or rubber nipple offered to the baby.

Thank you for taking the time to read our birth wishes and honoring them during this very important time in our lives.

______________________ signatures ____________________________

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Birthing Plan for __________________________________:

It is our intent to have a natural childbirth although we are open to medical interventions if needed. Thank you for taking the time to read our preferences.

We would like to request the following:

1. Please do not offer any drugs or medications to us during labor unless an emergency arises. The mother will request them if she wants to use them.

2. Minimal electronic fetal monitoring.

3. We would like to labor in quiet, and as undisturbed as possible.

4. It is important that the mother is able to move around freely during labor.

5. Please do not accelerate the labor process by artificially rupturing the membranes or administering drugs.

6. Episiotomy to be avoided with perineal massage, hot compresses and slow delivery, and the mother would prefer to deliver in a vertical position, if possible.

7. The baby is to be placed immediately on the mother's body after birth and remain there.

8. Please delay any routine exams or do them while the baby is in the mother's arms.

9. Please wait until the cord stops pulsating before cutting it.

10. The mother will be breastfeeding the baby as soon as she requests it. Therefore, in the event the baby needs to go to the nursery the mother will accompany the baby, using a wheelchair if necessary.

11. Please consult with us before administering any drugs, eyedrops, or drawing blood from the baby. Also, baby's bath to be attended/assisted by mother, father, or doula.

12. If the baby is a boy, we do not wish to have him circumcised.

13. In the event of a C-section:

1. We request the use of duramorph rather than morphine.

2. We request our doula attend the C-section with both of us.

3. We request to have the baby in recovery with the mother rather than in the nursery.

Thank you in advance for helping us achieve this birth as outlined above.

Sincerely, _________________________ _________________________

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______________________Family Birth Plan

Parents:

We are looking forward to working with the staff to ensure a safe and healthy delivery. We are presenting this birth plan to encourage dialogue and let you know what are wishes are. Our baby's health and well being is of primary importance to us. We appreciate your cooperation in helping our family to achieve our personal birthing goals.

LABOR AND BIRTH:

Please keep internal vaginal exams to a minimum.

I will need freedom of movement as my body dictates through out labor and delivery.

I may want to squat for the birth.

I would like minimal or no restrictions on food or drink.

I'd like a drug-free birth. I will ask for medication if I feel I need it.

I would like to be free of time limits on pushing. It is important to me to allow my body to operate in its natural rhythm and time-table.

I would like to avoid an episiotomy. Please use massage and warm oil to help me stretch.

I would like to deliver the placenta unassisted -- without Pitocin, uterine massage or cord traction. If a procedure is necessary, please explain it to me.

IMMEDIATE NEWBORN CARE:

I would like my baby not to be suctioned unless medically necessary.

I want my healthy baby will be immediately placed on my chest.

Please wait until the cord stops pulsating before it is clamped and cut.

No bottles, water, or a pacifier without our prior approval.

With either a vaginal or cesarean birth, I would like to postpone routine newborn procedures until I have had a chance to bond with my baby.

I would like to have any additional newborn procedures thoroughly explained to us.

I would like for my husband or myself to be present during all newborn procedures.

In the event our baby needs to go to the nursery we want our birth plan to continued to be honored.

CESAREAN DELIVERY:

It is important to me that my husband and doula be present with me at all times during the birth.

Please discuss anesthesia options with me. Please use duramorph instead of morphine.

Please allow the baby to come to recovery when I ask .

We thank you for taking the time to go over this Birth Plan, and appreciate your cooperation in getting our new family off to great start.

________________________ ___________________________

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