Birth Plan Template

Birth plans are important for a new mom to devise, especially before a first birth, just to get her focused on the questions that may come up during delivery.

Creating a birth plan is not writing a Bible for how your birth will go, but rather, it is a tool to think about, discuss with your caregivers, research, and form opinions on your birthing options. This way, you know the possibilities of what may come up, and if interventions become necessary, you at least understand why, and what to expect. Many mothers go in blindly, and I have spoken with a handful of clients who felt nothing short of violated during their birth.

A birth plan IS a good starting point to open conversation with your care provider. It IS a tool to get you both on the same page, and align your vision. It IS a way for you to educate yourself on your options for your birth. It IS to be addressed at prenatal appointments. If you are running into several issues with your doctor to agree to your birth plan, consider switching care providers. The nurses working at the hospital where the doctor works will follow typical protocol, and you will not have the time on your tiny's birthday to discuss your options with them. Be sure hospital protocol is similar to your plan, and if it isn't, find out why.

A birth plan is NOT something your doctor will have time to read the day of your birth. It is NOT a manual for care to give your nurses at your birth. It is NOT a guaranteed form of communication with your birth team.

So, in hopes of avoiding negative scenarios, here is a brief birth plan I use as a starting point for my clients.

                         Pampered Mama Doula Services

     That special power of loving that belongs to a woman is seen most clearly when she becomes a mother. –Mother Teresa

www.pamperedmama.weebly.com

Pampered Mama Birth Plan Template

This template is a tool used to plan for your IDEAL birth, and a visual guide for things to discuss before labor with your doctor to be sure you are comfortable and happy with your birthing experience.

Please Circle One for Each Category

Place of Delivery:   Hospital                   Birth Center        Home

Desired Birth:         Vaginal                          Caesarian  

Hep Lock?:              Yes                              No       

Pain Medication:   Yes (Epidural)           No                             Undecided

Induction:               Yes                              No                             Undecided

Pitocin:                    Yes                              No                             Undecided

“Water Breaking”: Artificial                    Natural 

Fetal Heart Monitoring: Interval              Constant            Undecided

*With the use of an epidural and/or Pitocin, your caregiver may not give the option of interval heart monitoring

Walking During Labor:                Yes                              No                           Undecided

*With the use of an epidural and/or Pitocin, you may not be able to move from the bed. If you feel it is important that you move around, you will need to tell your doctors and nurses beforehand.

Time to Push:                     On my back           Other          See what feels right

            If using an epidural:         _____ Lower dosage when fully dilated & wait to feel urge to push

                                               _____ Keep the medication and let doctor direct the pushing stage

Caregiver Role in birth:  Hands-On                  Hands-Off (mother left alone and catches baby)      

         Other: ___________________________________________________________

Pushing Method: Mother-Led Pushing         Directed/Coached Pushing          

Water Birth?:    Yes                                              No 

Episiotomy:        Never                                         Indifferent

Umbilical Cord: Clamped & Cut Immediately  Allowed to Stop Pulsing (Delayed)

Baby:                   Brought to Warmer                  Placed on Mama’s Chest

Other Things to Discuss:

Family/friends Present?              Yes                                          No                  

_____________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________

Meal During or After Birth? Can I eat during labor where I am birthing?

           _______________________________________________________________________________________________________________________________________________________________________________________________________________

Breastfeeding?:                             Yes                                          No      

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you plan to waive any newborn vaccines/tests? 

(What is administered to my baby at birth? Why?)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Baby’s First Bath?             Immediate               Do not wash baby

           _______________________________________________________________________________________________________________________________________________________________________________________________________________

Additional Thoughts/Requests:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________