A Simple Birth Plan Sample Outlining Your Wishes for the Birth of Your Baby
This is a simple birth plan sample that outlines the most important things to this mother. This gives you an idea of what a birth plan can look like. You can use it as a guide to make your own plan. The names on this birth plan sample have been removed to respect anonymity.
This format of birth plan highlights the most important choices to the mom in bullet points. This is a very simple format of birth plan. It's really easy to read because everything is separated into categories.
McKay Dee Hospital
Dr. or Midwife:
Estimated Due Date: May 21, 2010
• I am expecting that I will be pregnant past my due date. I would like to wait as long as possible for labor to begin on its own. Unless there is a medical necessity, I do not wish to induce labor prior to 42 weeks. It is important to me to avoid the use of pitocin if at all possible. I would like to try any natural means I can to start labor if I have not gone into labor by 41 weeks. If it becomes medically necessary to induce labor, I would like to try prostaglandins or amniotomy to induce before using pitocin.
• I plan on laboring at home as long as possible- until my water breaks or I feel it’s necessary for me to go to the hospital.
• I would like to avoid a routine IV. I would like a hep lock instead in case an IV becomes necessary.
• I plan on attempting to give birth naturally. I would like to use walking, a birthing ball, shower, or other natural methods to control the pain.
• I would like to have an epidural available, if I ask for it. I do not want pain relief offered to me by anyone. I will ask for it if I need it. I do not want narcotic pain relief. I would greatly appreciate the support of the hospital staff to have a natural birth.
• If labor is progressing and there are no complications, I would not like to have time limits imposed upon my labor.
• My support team includes my husband, my doula, and any other family members present at the hospital. Any of my visitors at the hospital during my labor are welcome to be present for the birth. Delivery
• Given that I do not have an epidural, I would like to have the option to give birth in whichever position I feel most comfortable.
• I would like to avoid an episiotomy.
• I do not want a mirror to see the birth.
• I would like my baby placed directly on my skin after birth and would like to breastfeed as soon as possible.
• If I do not have an epidural, I would like to delay cord clamping until pulsing stops. C-Section
I would like to do everything possible to avoid a C-section. If one becomes absolutely necessary:
• I would like to have the screen lowered so I can see the birth, if this is an option.
• I would like to breastfeed as soon as possible.
• I plan on breastfeeding exclusively. I do not mind if my baby is given a pacifier in the nursery, but I do not want her given formula.
Hopefully this birth plan sample gives you a starting point to make your own birth plan. Every birth is different, and every mom has different preferences. Using an outline like the birth plan sample above is a very simple way to let your support team know how they can best help you.
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