BIRTH PLAN TEMPLATE 
 
Feel free to cut and paste this birth plan template onto a word document for your own use. For more ideas on writing your birth plan click back to the Birth Plan page.
 ----------------------------------------------------------------------------------------------------------------------------------------------------
 
BIRTH PLAN FOR (insert your name)  
Place of Birth, First Preference (Change this for each of your potential birth scenarios i.e. "Second Preference" etc.)  	(i.e. home birth, birth centre, hospital etc.)	
Birth Companions	List your partner, doula, midwife, children etc. Do you mind having a student present? 	
Induction/Augmentation
 	List your preference and non preferences:
- Artificial Induction or Augmentation
- Membrane Sweep
- Natural Induction Methods, such as: castor oil, herbs, homeopathy, love making, meditation, aromatherapy, acupressure etc.	
Environment
 	List your preference and non preferences:
- Music
- Chatter
- Calm atmosphere
- Lighting	
First Stage of Labour 
 	List your preference and non preferences:
- Eating/drinking
- Mobility
- TENS Machine
- Entonox
- Pethidine 
- Epidural
- Water Pool
- Massage
- Aromatherapy/hypnobirthing/homeopathy 
- Hot/cold packs     	
Foetal monitoring / Vaginal Examinations	List the type, if any, of foetal monitoring you prefer; Electronic or Doppler. 
State your preference regarding VE (vaginal examinations).	
Second Stage of Labour
 	List your preference and non preferences:
- Position
- Pushing
- Touching baby’s head
- Discovering the sex
- Photos	
Assisted Delivery
 	List your preference and non preferences:
- Forceps, 
- Ventouse
- Episiotomy
- Perennial massage/hot compresses 	
Cutting the Cord	List your preference and non preferences:
- How long would you like to wait after the birth before cutting the cord?
- Who would you like to cut it i.e. your partner? 
- If you are planning a lotus birth, list that here. 
- Would you like to keep the placenta?	
Third Stage of Labour	List your preference and non preferences:
- Syntometrine 
- Syntocinon
- Pulling on the cord etc
- Herbs/homeopathy
- Fundal pressure
- Breast Feeding	
Fourth Stage of Labour (postpartum)	List your preference and non preferences:
- Bonding/skin to skin Immediately after birth 
- Weighing, measuring, washing and dressing baby
- When would you like to shower or bathe?
- When would you like to eat or drink 	
Baby Care	List your preference and non preferences:
- Skin to skin contact
- Breast feeding
- Pacifiers 
- Glucose water 
- circumcision if the baby is a boy
- Vitamin K
- vaccinations	
In Case of an Emergency, Caesarean Birth or Sick Baby 
Advocate - In an emergency, if I am unable to speak for myself, I would like the following person to be my advocate.	State who you would like to advocate for you in the situation that you are unable, i.e. your husband, doula, or midwife etc. 	
Birth Companions	List your partner, doula, midwife, children etc. Do you mind having a student present? 	
Induction/Augmentation
 	List your preference and non preferences:
- Artificial Induction or Augmentation
- Membrane Sweep
- Natural Induction Methods, such as: castor oil, herbs, homeopathy, love making, meditation, aromatherapy, acupressure etc.	
Environment
 	List your preference and non preferences:
- Music
- Chatter
- Calm atmosphere
- Lighting	
First Stage of Labour 
 	List your preference and non preferences:
- Eating/drinking
- Mobility
- TENS Machine
- Entonox
- Pethidine 
- Epidural
- Water Pool
- Massage
- Aromatherapy/hypnobirthing/homeopathy 
- Hot/cold packs     	
Foetal monitoring / Vaginal Examinations	List the type, if any, of foetal monitoring you prefer; Electronic or Doppler. 
State your preference regarding VE (vaginal examinations).	
Second Stage of Labour
 	List your preference and non preferences:
- Position
- Pushing
- Touching baby’s head
- Discovering the sex
- Photos	
Assisted Delivery
 	List your preference and non preferences:
- Forceps, 
- Ventouse
- Episiotomy
- Perennial massage/hot compresses 	
Cutting the Cord	List your preference and non preferences:
- How long would you like to wait after the birth before cutting the cord?
- Who would you like to cut it i.e. your partner? 
- If you are planning a lotus birth, list that here. 
- Would you like to keep the placenta?	
Third Stage of Labour	List your preference and non preferences:
- Syntometrine 
- Syntocinon
- Pulling on the cord etc
- Herbs/homeopathy
- Fundal pressure
- Breast Feeding	
Fourth Stage of Labour (postpartum)	List your preference and non preferences:
- Bonding/skin to skin Immediately after birth 
- Weighing, measuring, washing and dressing baby
- When would you like to shower or bathe?
- When would you like to eat or drink 	
Baby Care	List your preference and non preferences:
- Skin to skin contact
- Breast feeding
- Pacifiers 
- Glucose water 
- circumcision if the baby is a boy
- Vitamin K
- vaccinations