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Create A Birth Plan

A birth plan is a list of wants you hope to obtain throughout your labor and birth.

Due to being in a more vulnerable position during labor, having a written birth plan helps your team
fulfill your dream.

Birth plans are a written means of communication and should be added to as needed for you to feel
like your wishes are known.

Birth Plan Form

Birth Plan for &

Labor & Birth

Things I will bring or have to assist in labor:


Hypnatherapy tape

Low Lights
Minimal vaginal exams

I do not want to have the following interventions unless medically necessary and only after I have
been informed of need and participated in the decision making process.

IV therapy
Continuous external fetal monitoring
Internal monitoring
Rupture of membranes
Narcotic pain relief such as Nubain, Demerol, Stadol, Etc.
Epidural anesthetic
Induction of labor by Prostaglaudins and Oxytocins
Augmentation of labor with Oxytocins unless more natural methods such as nipple stimulation,       herbals and homeopathics have failed.
Agressive perineal massage
Neonatal hepatitis B vaccine the first 24 hours after birth.
Pacifiers and/or nipples if supplements are medically necessary.

I have done the following to prepare for the birthing process:

Childbirth classes/reading
Daily activity such as walking, yoga, belly dancing
Kegels and/or squatting
Perineal massage
Postpartum in home help
Participated in Le Leche League groups or other breastfeeding support.

I would like the following interventions and procedures:

To deliver in hands/knees, squat, or side-lying position.
To push only with the urge to push.
To watch the birth with use of a mirror
To touch my babies head as it crowns/births.
Support during crowning
To have my baby placed on my abdomen.
Delayed cord clamping
Episiotomy only if necessary for the well being of the baby.
Local anesthetic for repair of a tear or episiotomy
Cord cut by signifant other
Baby intervention and assessment in my presence and/or on my abdomen.
Eye prophylaxsis held for first 2 hours to facilitate bonding.
Umbilical cord banking
Placenta donated to Missouri Search and Rescue

If a cesarean birth was necessary for the health of my baby or myself, I prefer if possible:

General anesthetic
Epidual anesthetic
Support people present
FOB/SO present with the baby after delivery
FOB/SO accompany baby to nursery if nessary
Support person in recovery area with me
Breastfeeding initiated in recovery or asap unless medical reasons cause delay.


I wish to take pictures/videos of the birth
I do not want the baby circumcised
I do want to be present during the circumcision
I want a significant other present for the circumcision

My Birth Team

Name Relationship Job/Age (If younger than 20)

*** Important Note ***

Please print off one copy of the birth plan that you have completed and bring it with you on
your next visit to The Woman's Hour.

Copyright 2003 The Women's Health Pavilion