Birth Plan Template - Hospital

The way in which we are made to feel as we birth our children, sets the tone for the journey of parenthood. Understanding the aspects of the birth process that matter to you the most will support you in cultivating a birth plan or a birth preference sheet that illustrates the specific qualities you wish to integrate into your birth experience. This is an act of honoring ourselves, of weaving a deeper sense of significance to the experience of bringing life into the world. 

Birth Plans for the Hospital 

Creating a birth plan gives the people supporting you a guide to inform them as to how to support you in alignment with your desires. If you’re heavily influenced by the language surrounding birth, you may wish to create a birth preference sheet rather than a birth plan. I find that some people feel more flexible in labor with the creation of a birth preference sheet, as the illustration of desires is truly a preference, not a plan. We can plan the container that holds birth, but we cannot plan birth itself. 

When choosing a birth team, I encourage you to be mindful of how they respond to your birth preferences. A response such as, “thank you for sharing this with us,” may help you to feel heard, supported and respected. A care provider, doula or other birth team member who appears to be uninterested in reading your birth plan, may flag a need for you to reevaluate if you want them to be present for your birth. 

If you intend to give birth at a hospital or birth center, you may wish to create a birth plan illustrating your choices for accepting or refusing certain medications, and illustrating preferences for interventions. Incorporating your intentions for your birth, listing your support people and illustrating the ways in which you prefer to be supported may be helpful as well. 

A birth plan template is below, as well as attached as a downloadable form on this article. If you plan to birth at home, refer to my home birth plan template here: Birth Plan Template for Birth Center or Home. If you’re interested in my online childbirth class, learn more here: The Comprehensive Guide to Sovereign Birth

Birth Plan Template - Hospital

Name:

Due Date:

Support People: 

Birth Intention: (Peace, Joy, Ecstatic, Gentle, etc)

Accept/Decline

• I (accept/decline) the vitamin K injection for my newborn.
• I (accept/decline) the hepatitis B injection for my newborn.
• I (accept/decline) erythromycin or any antibiotic eye ointment for my newborn.
• If positive with group beta strep, I (accept/refuse) IV antibiotic treatment.
• I (accept/decline) the placement of an IV port in labor.

Preferences for Labor Support (Choose Any)

• Birth tub
• Position changes
• Massage
• Rebozo 
• Essential oils
• Music 
• Cold washcloths 
• Birth ball 
• Peanut ball
• Shower
• Birth stool 
• Doula/support people
• Sterile water injections
• Tens unit 

Induction (Choose One)

• If the need for induction were to arise, I prefer to attempt natural labor induction methods before opting into medicated augmentation.
• If the need for induction were to arise, I prefer to attempt my care provider’s suggested form of medical augmentation.

Pitocin in Labor (Choose One) 

• If labor stalls or does not progress efficiently, I prefer to try natural methods for labor encouragement such as nipple stimulation, privacy and position changes.
• If labor stalls or does not progress efficiently, and pitocin is suggested, I prefer to begin with a small amount of pitocin to encourage progression.
• If labor stalls or does not progress efficiently, I prefer to follow my care provider’s recommendations for encouraging labor. 

Pain Medications in Labor (Choose One)

• I desire a natural, vaginal birth with no use of pain medications. I prefer not to be offered pain medications in labor. 
• I wish to attempt a natural birth, but if labor prolongs and I struggle to cope well, I welcome the recommendation for pain management medications. 
• I plan to utilize pain management medications in labor, and I have discussed the risks and benefits prenatally with my care provider.

Forceps/Vacuum (Choose One)

• I wish to avoid an instrumental delivery to the best of my ability. I wish to try alternative pushing positions to expedite delivery before implementing forceps or vacuum, outside of the presence of an emergency.  
• I welcome the use of an instrumental delivery per my care provider’s recommendation.

Vaginal Exams (Choose One)

• I prefer not to receive any vaginal exams in labor. 
• I prefer only to receive a vaginal exam in labor per my request. 
• I welcome the use of vaginal exams per my care provider’s recommendation. 
• (Choose one) If I were to receive a vaginal exam, please (do/don’t) share the results (dilation, effacement and station) with me.

External Fetal Monitoring (Choose One)

• I prefer to avoid external fetal monitoring, and monitor fetal heart tones intermittently instead. I accept external fetal monitoring with the use of medications in labor.
• I welcome the use of external fetal monitoring per my care provider’s recommendation. 

Internal Fetal Monitoring (Choose One)

• I refuse the use of internal fetal monitoring.
• I prefer to avoid internal fetal monitoring, but I consent in the presence of an emergency.
• I consent to the use of internal fetal monitoring per my care provider’s recommendation. 

AROM (Choose One)

• I decline the use of AROM to induce labor, and during my labor.
• I prefer to avoid AROM, but I will consent to induce labor if needed, or in the presence of a prolonged 1st or 2nd stage of labor.
• I decline the use of AROM to induce labor, but I consent to AROM in the presence of a prolonged 1st or 2nd stage of labor.
• I accept the use of AROM per my care provider’s recommendation. 

Pushing (Choose One)

• I prefer to avoid directed pushing, and allow for my body to push naturally.
• I welcome the use of directed pushing in the presence of a prolonged 2nd stage to expedite delivery.
• I welcome the use of directed pushing per my care provider’s recommendation.

Episiotomy (Choose One)

• I decline the use of episiotomy.
• I prefer to avoid episiotomy, but I will consent in the presence of an emergency.
• I consent to the use of episiotomy per my care provider’s recommendation. 

Vaginal Lacerations (Choose One)

• I prefer to have a vaginal laceration sutured per my care provider’s recommendation.
• If the tear is small enough, I prefer to avoid suturing.

Tearing Prevention (Choose Any)

• I (accept/decline) the use of hot compresses to prevent tearing.
• I (accept/decline) the use of vaginal massage to prevent tearing.
• I (accept/decline) the use of hands on perineal support to prevent tearing.
• I (accept/decline) the use of labor and/or delivery in a birth tub to prevent tearing.
• I (accept/decline) the use of verbal guidance, supporting a slow and controlled delivery to prevent tearing.

Delivery (Choose One)

• I welcome my care provider to catch my baby.
• My support person wishes to catch my baby with the guidance/support of my care provider.
• I intend to catch my own baby, if I am able to in the moment.

Location (Choose One)

• I prefer to deliver in the birthing tub.
• I prefer to deliver on the bed. 
• I prefer to deliver in (other specified location).

Placenta Delivery (Choose One)

• I prefer to deliver my placenta on my own, outside the presence of a hemorrhage.
• I welcome the use of gentle guidance to assist me in delivering my placenta.
• I prefer for a provider to wait until I feel cramping sensations before assisting in the delivery of my placenta, outside the presence of a hemorrhage.

Placenta Plan (Choose One)

• I plan to take my placenta home.
• I plan for a (friend, encapsulation specialist, etc) to pick up my placenta. 
• You may dispose of my placenta. 

Cesarean (Choose Any)

• I prefer not to have a cesarean unless an emergency were to arise.
• I opt into a cesarean in the presence of a prolonged labor, per my care provider’s recommendation.
• In the presence of a prolonged labor, rather than receiving a cesarean, I prefer to attempt natural or medicinal methods for promoting labor progression unless my baby is in distress.
• If I have a cesarean, I prefer immediate skin to skin contact.
• If I have a cesarean, I prefer delayed cord clamping.
• If I have a cesarean, I prefer to apply a vaginal swab over my baby’s mouth. 
• If I have a cesarean, I prefer for my (partner, mother, spouse, doula, etc) to be present. 

Newborn (Choose Any)

• Please delay cutting the cord until it is done pulsing.
• We plan to burn the cord, please do not cut it.
• Please leave the vernix on my baby.
• If my baby if vigorous upon birth, please allow me to stimulate my own baby. 
• We wish for as much privacy and reverence as possible after the baby is born.
• We intend to have at least one hour of uninterrupted skin to skin time after birth.
• If I am unable to be skin to skin with my newborn, I prefer for my support person (partner, doula, mother, friend, etc) to hold my newborn skin to skin.

Feeding (Choose Any)

• We intend to breastfeed. 
• We intend to bottle feed formula.
• We intend to bottle feed donated milk.
• We intend to use an SNS system.
• We welcome lactation support in the presence of feeding challenges. 

Hemorrhage (Choose Any)

• In the presence of a hemorrhage, I consent to the use of all hemorrhage medications including mifepristone, misoprostol and pitocin. 
• If possible, I wish to attempt the use of pitocin before using mifepristone or misoprostol to control postpartum bleeding.
• I welcome an injection or IV administration of pitocin immediately after birth.
• I decline routine use of pitocin for hemorrhage prevention, and only consent to the use of hemorrhage medications in the presence of a hemorrhage. 

Other Preferences (Choose Any)

• I prefer as much privacy as possible.
• I prefer minimal to no interventions, if possible.
• I prefer for the room to be as quiet as possible.
• I prefer for only 2 family members in the room at a time postpartum.
• I prefer no visitors for the first hour postpartum. 
• I prefer to have no one hold my baby aside from (myself/my partner and I) in immediate postpartum. 
• I prefer to labor and birth in whatever position comes naturally to me.