Birth Plan Worksheet: Create A Customized Birth Plan

Creating a personalized birth plan in advance is a great way to help you communicate your preferences to your healthcare provider. A well-crafted birth plan can make you feel more informed and in control of your childbirth experience. To start, you want to identify exactly what it is you desire from your birth experience. This worksheet will get you started on creating a customized birth plan that reflects your preferences and priorities. Be sure to discuss this at length with your healthcare provider to ensure your wishes align with their approach. With proper communication and preparation, you can have a safe and joyful birth experience.

Key Points of Creating a Birth Plan

• Do your research beforehand and speak to your doctor about your ideal birth plan.
• Determine the type of environment your desire when giving birth.
• Decide who you want present while giving birth.
• Craft a backup plan in the event a cesarean is needed.

Labor Birth Plan Worksheet

There are many options available to you when preparing for childbirth it can get overwhelming. From the type of environment to who will be present, there are a lot of decisions to make before you even arrive at the hospital. This is where preparation is key. Knowing how you and your partner want to experience the birth of your child in advance can help you achieve a safe and satisfying event. Use the following worksheet to help determine your ideal birth plan. Circle the option that best fits your needs.

1. I would like to give birth:

at home
in a birthing room
in a delivery room (more surgical facilities)
in the shower

2. In my birthing room, the following is important to me:

Dimmed lights
Soft music playing
Wearing my own clothes during delivery

3. I would like to have the following people present at the birth:

Partner
Parents
Friend(s) 
Relatives

4. In preparation for my delivery, I would prefer:

to use/to not use an enema
to be/to not be induced if I go past my due date

5. If inducing labor, I would prefer these methods:

Breaking the membrane
Castor oil
Nipple stimulation
Walking
Sexual intercourse
Acupuncture
Pitocin

6. During the first stage of labor:

I would/would not prefer to remain with my partner during labor or delivery
I would like to eat or drink during labor
Give me pain medication only if I ask for it/if the pain causes me too much discomfort
I would prefer not to undergo internal exams unless medically necessary for the health of me or my baby.

7. Ways I would like to manage the pain:

Massage
Breathing techniques
Hypnosis
Relaxation
Medication
Distraction
Acupuncture

8. Second stage of labor:

I would prefer not to have an episiotomy, even if it means tearing vaginal tissue
I would prefer having an episiotomy if there is a possibility of tissue tearing
Unless it's medically necessary, I would prefer not to have an episiotomy offered to me

9. I prefer to give birth in the following position:

Classic position-semi-reclined
Standing upright
Lying on my side
Squatting
Hands and knees

10. During my birth:

If it's necessary to extract the baby, use either forceps or a vacuum
I would like a mirror available so that I might see my baby's head
I would like to touch my vaginal area as my baby's head crowns

11. After delivery:

I wish to cut the umbilical cord myself
I wish to have umbilical cord blood preserved
I would like a private room
If my newborn leaves my presence, I would like my partner to attend to her

Cesarean Section Birth Plan

Whether using a cesarean as your backup plan or even your original birth plan, it's important to finalize the details. When writing your cesarean birth plan you have a few options available to you. You can choose whether to elect a c-section ahead of time, who you want in the room with you, and whether you want any medical students in the room with you. Remember, even if a cesarean is your Plan B, it's important to communicate to your healthcare provider what's important to you.

Midwife Birth Plan

If you are considering a midwife, you want to be sure your birth plan outlines your preferences. Midwives are specifically trained to provide care that respects the mother's choices. For instance, you should decide whether you want to have a water birth or stay in the bedroom. You can also choose to invite your partner, parents, relatives, and friends. Be sure to include any information about pain meds or interventions during labor, and communicate this to your midwife.

Interactive Birth Plans

An interactive birth plan will provide you with a checklist of possible options you may want to consider and speak with your doctor about. Once you have discussed the options, you then fill out your final birth plan and print three copies-one for your partner, one for the doctor, and one for the hospital staff looking after you. You can simply use a sample birth plan as a place to start discussing options with your practitioner.