I previously blogged on an example of a simple birth plan, but I also wanted to provide you with an example of a more formal birth plan format for those of you who want to be more detailed. Remember to keep your birth plan to a page and be as clear and specific as possible.

Birth Plan for (mother’s name)
Due Date: ________
Patient of Dr. _________
Scheduled to deliver at ________ Medical Center

Dear Dr. __________ and the Medical Center Staff:

I look forward to sharing my upcoming birth with you. I have created the following birth plan to help you understanding my preferences for my upcoming labor and delivery. I fully understand that in certain circumstances these guidelines may not be followed, but it is my hope that you will assist me in making this the experience I hope for. If you have any questions or suggestions let me know.

Sincerely,
(mother’s name)

Labor
• I would prefer to avoid an enema and/or shaving of pubic hair
• I wish to be able to walk, move around and change position at will throughout labor
• I would like to be able to have fluids by mouth throughout the first stage of labor
• I would prefer to keep the number of vaginal exams to a minimum
Monitoring
• I do not wish to have continuous fetal monitoring unless it is required or an IV put in my arm “just in case”
Labor Augmentation/Induction
• I do not wish for my amniotic membranes ruptured artificially unless signs of fetal distress require internal monitoring
• I would prefer to be allowed to try positions before pitocin is administered
Pain Medications
• I do not want any kind of medication/anesthesia offered to me during labor, though I would like it available if I specifically request it. I will ask if I need any pain medications, including an epidural
Cesarean
• I would like my husband present at all times if my son requires a Cesarean delivery
• I wish to have an epidural for anesthesia
• If my son is not in distress, I would like my son shown to my husband and I immediately after birth
Episiotomy
• I would prefer not to have an episiotomy unless absolutely required for the baby’s safety. I realize that mean I may tear naturally.
Delivery
• I would like my husband &/or mother to support my legs as necessary during the pushing stage
• I would like to have my son placed on my stomach/chest immediately after delivery
After Delivery
• I would like my husband to cut the cord
• I would prefer my son be examined and bathed in my presence
• If my son must be taken from me to receive medical treatment, my husband will accompany him at all times
• I would like a private room if available
Breastfeeding
• I plan to breastfeed and I do not want any bottles given to my son (including glucose water or plain water). I do not want my son given a pacifier.
Photos
• I would like to make a video recording of labor, not necessarily the birth
Other
• My husband, ______, will be with me throughout the birth as well as my mother, _______.

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