Birth Plan Template

To my birth attendants:

As a mother, I understand and accept the fact that I am ultimately responsible for my own health and the health of my baby.  I have made every effort to gain the knowledge and information that I need to make informed decisions.  After a careful consideration of this knowledge as well as my own values and priorities, I have established some guidelines to help you care for me in a way which is not only the safest for me and my baby, but also honors my needs and beliefs about birth.

I have complete faith in my body's ability to give birth naturally and normally.  I believe my body was designed to give birth, and that it can do so with very little assistance.  I have prepared myself for what the birth experience will be like by taking classes and talking with mothers who have had a positive birth experience to find out what they did that was helpful.  I do not expect to have a short labor or to have no discomfort.  But I do expect to be allowed to labor in the way that is most helpful to me, even if that way is in conflict with routine procedures.  With help from my labor support person, I will require very little of your time and attention.

I have chosen a labor support person to be my birth advocate, and I authorize this person to see that my preferences as stated in this birth plan are carried out as closely as possible.  This person will also provide physical and emotional support throughout the whole process of labor and delivery.  If at any time a physician feels that medical conditions warrant an intervention into the birth process, I am willing to discuss the proposed intervention as well as the possible alternatives.

After discussing the situation, I will expect my final decision to be respected and honored, even if it is in opposition to the opinions of others.

The following guidelines are designed to help my birth attendants know what kind of birth experience I desire for myself and my baby.  No deviations should be made from this plan without my consent:

1.  I will not be separated from my support persons for any reason unless I request it.

2.  I will have no perineal shave-prep.

3.  My amniotic membranes will be allowed to rupture spontaneously

4.  Pelvic exams will be performed only at my request.

5.  Because of my belief that ultrasound is an unproven and possible unsafe technology, no electronic monitors or dopplers will be used.  Monitoring of fetal heart tones will be done through fetoscope only.

6.  I will be upright and active throughout my labor, walking as much or as little as I feel necessary, and assuming whatever position is most comfortable for me and helps assist the progress of labor.

7.  I will eat light, non-constipating foods during early labor and clear liquids during active labor, if desired.

8.  No drugs of any kind will be administered during the labor and delivery process.  I request that no offers for anesthesia be made to me by any doctor, nurse, or other hospital staff person.  In the event that a cesarean section becomes necessary, I will decide at that time what kind of anesthesia will be used.

9.  No episiotomy will be performed on me under any circumstances.  Perineal massage with oil, hot compresses, and perineal support will be used instead to prepare the perineal tissues to stretch.  In the event that tearing of these tissues seems likely, I would prefer to allow the tissues to tear rather than be cut.

10. In order to allow the perineal tissues time to fan out so that no tearing takes place, and in order to reduce the risk of damage to the muscles of the pelvic floor, I will allow the baby to descend through the birth canal slowly and without sustained pushing efforts from me.  Only exhale pushing will be used, and only when I feel the urge to do so.  As long as fetal heart tones are good, delivery will not be rushed, but allowed to occur slowly and naturally.

11. It is my choice to give birth in the squatting position because of the obvious advantages it offers.  If squat bars are not available, I will have two labor support persons with me to physically support me in this position while I give birth.  I will require very little help from doctors or nurses to give birth because the squatting position encourages proper rotation, as well as quick and painless expulsion of the baby.

12. During labor and delivery I will be using vocalization as one of my tools for coping with labor.  I find that it helps me to cope with the intensity of contractions while remaining totally relaxed.  Hospital staff need to be aware that these vocalizations are constructive and that I am not making them because I am in pain, am distress, or need assistance.

13.  It is my desire to receive no assistance of any kind with my birth unless I specifically ask for that assistance.  I am at the hospital only so that emergency help is available if necessary.  I will require no routine care of any kind.

14.  The delivery will take place in a quiet, respectful atmosphere with dimmed lights, soft music, and quiet, calm speaking if speaking is necessary.

15.  As soon as the infant is delivered it is to be placed on my chest and observed for APGAR there.  The infant will be allowed to nurse as desired so as to hasten the detachment and delivery of the placenta.

16.  If the body temperature of the baby is of concern, the baby will be placed skin-to-skin with me and a warmed blanket will be spread over us both.  At no time will the baby be separated from me and placed in a warmer.

17.  At no time will my baby be separated from me.  All newborn care will be done in the same room with me and preferably with the baby in my arms.

18.  Since I have been tested for Gonorrhea, and my husband and I are in a monogamous relationship, I prefer that no eye drops or ointment be used in my baby's eyes.

19. My baby will be given no substance by mouth other than my breastmilk or colostrum.  At no time will sterile water, glucose water, or formula of any kind be given.  The baby will be allowed to nurse on demand, and no rubber nipples or pacifiers will be given.  If the baby's blood sugar level is of concern, more frequent nursing will be encouraged, since maternal colostrum provides a healthier and more stable blood sugar level than processed glucose.

20.  When one gives birth in the squatting position, suctioning of the baby is rarely necessary due to the natural drainage of fluids.  If suction does prove to be necessary, deep suctioning of the infant will be done only if suction with a bulb syringe proves to be inadequate.

21.  I request that a warm Leboyer bath be provided within one hour after birth to allow the baby to make a smooth and comfortable transition into the world.  No soaps or disinfecting agents will be used to wash the baby, and vernix on his skin will be massaged into the skin rather than removed through washing.

22.  Absolutely no procedure will be performed on my baby without my authorization and I will be present for any procedure that is performed.

23.  The umbilical cord will not be cut until it has stopped pulsating.

24.  Vitamin K shot will not be given under any circumstances.  If the baby is a boy, there will be no circumcision.

25.  No PKU test will be administered in the hospital because the baby must nurse for at least two days before this is done.  It will be my responsibility to see that the test is performed by a pediatrician at a later time.

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________________________Printed Name

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Thanks to The Center for Unhindered Living for this Sample Birth Plan!