Birth Plan Example

Here is an example of a natural hospital birth plan. ūüôā Shared with permission.

Birth Plan

My Due Date:
My Doctor:
My Partner:
My Doula: Kali Park

We desire a labor and delivery that is as free from medication and other medical interventions as possible. We strongly prefer a vaginal delivery. Please discuss any suggested interventions or procedures with all of us and obtain our verbal consent before initiating any such interventions or procedures. I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth plan before deviating from it. Thank you for working with us to help create a positive birth experience for me and my baby.

. I would like to go at least 12 to 14 days over my due date before considering inducing labor
. Try natural induction techniques first if induction is indicated.

First Stage Labor
.  Monitored by intermittent monitoring
.  No augmentation of labor such as pitocin, breaking the water unless non-medical techniques  are not effective
. Husband and doula are to be present at all times
. No pain medication offered unless we ask for it
. Freedom to move/walk around during labor
. Freedom to eat and drink during labor as needed
. No IV desired, but if necessary, Heparin lock
. I would prefer to wear my own clothes
. If available, I would like to use: a tub, shower, and squatting bar

Second Stage Labor
. Choice of positions for pushing – no stirrups for birth please
. No time limits on pushing if progress is being made
. Spontaneous bearing down
. I prefer to have no episiotomy
. To help prevent tearing, please apply: warm compresses, oil, counter pressure
. Gender of baby is unknown, please allow my partner to announce the sex

Third Stage
. Delay cord cutting until it has stopped pulsating
. Natural delivery of placenta
. No post-delivery pitocin or pulling on the cord please
.I will be taking my placenta home with me, please save it on ice.

After Birth
. I would like my baby placed immediately on my abdomen following the birth
. Baby to breastfeed immediately; please delay newborn procedures until baby has had the opportunity to breastfeed
. I do not consent to the following: erythromycin eye ointment, Hep B vaccination (or any vaccinations), and circumcision. I will gladly sign my forms to refuse these things.
. Delay the administration of vitamin K up to 2 hours after birth unless medically necessary
. We would like to give our baby its first bath. Please help direct us in this process at the hospital

We appreciate all that you do. Thank you!