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Sample Birth Plan

Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

Sample Birth Plan
Parents Mark & Mary Jones
Baby Michael
Dr. Les Payne
Doula Ann Hodge, CD (DONA)

We are thrilled, first—time parents, looking forward to a good and safe birth. Our Doula, Amy, will accompany us throughout labor and the birth of our son. Since we are new to labor and birth. Please help US to understand all the changes taking place as well as procedures and protocols.

• For hydration during labor. Mary prefers to drink clear liquids rather than receive an IV drip.
• We wish to use the EFM minimally.
• Mobility is key for us. We’d like to walk and be able to change positions.
• Wed like access to a birth ball, shower, and tub to help manage pain.
• Please do not offer pain medication.
• Limited cervical checks are preferable. Please do not inform Mary of her progress. Mark and Amy should be advised of cervical change.

• We ask our physicians assistance in avoiding episiotomy.
• Mary wishes to push as the urge comes rather than to hold her breath and count to ten during pushing.
• We’d like to use the sidelying or squatting positions for birth.
• Mark would like to cut the cord, once it stops pulsating.
• Low lights and soft voices are preferable.

Newborn Care:
• Michael will be exclusively breastfed. Please do not give him pacifiers or supplements of any kind.
• Mary would like to hold and nurse Michael immediately after his birth.
• ‘We wish to waive eye prophylaxis and will sign the necessary forms.
• Routine deep suctioning is to be avoided unless meconium aspiration is a concern.
• Mark would like to give Michael his first bath.
• Please delay weighing and measuring for a short while to allow us to bond with our baby.
• We do not plan to circumcise our son.
• We expect to room-in. If Michael ever needs care outside his mother’s room. one of us will accompany him.
• Mary would like to have a visit from a lactation consultant soon after the birth.

Unexpected Situations:
• If a cesarean is medically indicated, we prefer that OR staff not carry on unnecessary conversations Talk about the birth. and let us know what is happening. Both Mark and Amy will support Mary in surgery.
• If mother and child need to be separated. Amy will remain with Mary. while Mark accompanies Michael.
• If Michael is unable to nurse, Mary wishes to use a hospital-grade breastpump to express milk and build a supply as soon as possible. We will purchase our own kit. Please do not microwave breastmilk to thaw it.

**Author’s note: All names are fictitious except for my own.
International Doula Volume II, Issue 4

This Web page is referenced from another page containing related information about Birth Plans


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