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 Unmedicated birth

3. Monitoring Preferences

Intermittent monitoring

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

• Breastfeeding only
• Vitamin K: Injection
• Eye ointment: Accept
• Hepatitis B vaccine: Accept

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]