Birth Plan Worksheet

My Practical Birth Plan Worksheet

Second Stage Labor

When it's time to push, I'd like to:

Push in position of my choosing

Squat/Birthing Bar

Pushing while on hands and knees

I am not concerned with positioning

Foot pedals rather than stirrups

People as leg support rather than stirrups

Spontaneous pushing (when I feel the need)

Pushing with medical direction


I would like to touch baby's head when it crowns

I would like a mirror available to view pushing/crowning/birth

Immediately Following Delivery

I want baby placed on my chest immediately after birth

I would like my partner/coach to cut the cord

I would like to cut the cord

Partner/coach does not want to cut cord

Please delay cord clamping and cutting until pulsating ceases

I would like to hold the baby while delivery placenta

I do not wish a pitocin injection to assist with placenta delivery

I wish baby to be examined in my presence

If baby cannot be examined in my presence, I wish my partner/coach to remain with baby at all times

I do not wish baby to be placed under heat lamps; I will hold baby and provide body warmth instead

I want to donate cord blood

I want to bank cord blood


I do not want an episiotomy unless there is an emergency situation

I would like to attempt perineal massage to stretch the perineum.

I would like an episiotomy to reduce risk of tearing

I would like a local anesthetic during repair of tear/episiotomy

I would not like a local anesthetic during repair of tear/episiotomy

Baby Care

I wish to breastfeed exclusively

I wish to breastfeed, but formula supplementation is acceptable

I wish to formula feed

I do not want baby to be given a pacifier

I would like to meet with a lactation consultant as soon as possible

I want baby circumcised

I do not want baby circumcised


I would like a private room, I understand that there will be an additional charge

I would like baby to "room in"

I would like baby to sleep in nursery

I would like baby to be brought to me for all feedings

I welcome all well wishers

I wish to limit visitors

I would prefer my door closed with a sign requesting that visitors and staff members knock before entering

I do not wish to have medical students involved in my care

Other ___________________________________________

In the Event that Baby Requires Special Care Due to Trauma or Illness:

I would like to breastfeed/pump breast milk

Partner/coach will accompany baby if transferred to another hospital

I would like to be transferred to baby's hospital

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