Sample Birth Plan

Here's a sample birth plan that's super easy to read and follow. This is the format I always use to write birth plans for my clients. There's no wrong way to write a birth plan, but I like to keep them simple and easy to skim over.

This birth plan is an actual plan I wrote for one of my clients. I changed her name to protect privacy.

Jan Smith's Birth Plan

Estimated Due Date: 1/12/14
OB: Dr. Hurst
Doula: Stephanie Mitchell

-I would like to wear my own clothing

-Please keep low lighting

-No students please

-I plan to eat and drink as needed/desired

-Please no routine electronic monitoring- I prefer intermittent monitoring via Doppler (this has been discussed and approved by Dr. Hurst).

-I do not want routine vaginal exams if my labor appears to be progressing normally.

-I plan to avoid Pitocin if at all possible- please do not suggest or offer unless absolutely necessary.

- I plan to allow cervical dilation to occur naturally without time expectations.

Pain Management:
-I plan to use natural pain relief methods.

-Please do not offer any pain medication or epidural- I will ask if it becomes necessary.

-I wish to push in whatever position is most comfortable- I do not plan to push lying down unless I choose to do so.

-Please allow me to push only at my urge.

-NO episiotomy- I prefer to tear.

-I would like cord clamping delayed.

-Immediate skin-to-skin.

-Exclusive breastfeeding on-demand.

-Please do not give my baby any pacifiers or bottles.

-I do not want my baby to have eye ointment.

-Please do not bathe my baby.

-No Hep B vaccine.

-Please do give our baby a vitamin K shot.

-I would like all procedures- measurements included- to be delayed until after mom-baby bonding time.

Other: If deviation from this plan becomes necessary, please give us time alone to discuss and consider all of our options without pressure. 

We appreciate your support in our desire to have a natural birth, as hands-off as possible. Thank you!

Click here to check out another sample birth plan
Click here to see a sample birth plan letter

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