Free Birth Plan Template

Parent's Name: [Your Full Name]

Expected Due Date: [Date]

Hospital or Birthing Center: [Facility Name]

Care Provider: [Doctor / Midwife Name]

Support Person(s): [Partner, Doula, Family Member]

"This Plan outlines my preferences for labor, delivery, and immediate postpartum care. I understand that flexibility may be required based on medical circumstances."

1. "Labor Preferences"

I would like to:

2. "Pain Management"

"I prefer" Sans Médicament

3. "Monitoring Preferences"

Intermittent

4. "Interventions"

I would like to avoid "(unless medically necessary)":

5. "Support During Labor"

"I would like the following people present": [Names of people allowed in delivery room]

6. "Delivery Preferences"

I would like to:

7. "After Birth"

I would like:

8. "Baby Care"

• Allaitement
• Vitamin K: Injection
• Eye ointment: Accepter
• Hepatitis B vaccine: Accepter

9. "Unexpected Situations"

If a C-section is required, I would prefer:

Acknowledgment

"I understand that while every effort will be made to follow this Plan, medical needs and circumstances may require adjustments. I trust my care team to act in the best interest of myself and my baby."

Signature

"Name": ___________________________

"Date": [Date]