Worksheet Template For Preparing Your Birth Plan With Samples (Page 6 of 14) in pdf

Pregnancy, Childbirth, and the Newborn

Birth Plan for Jason and Xiaoling

We are committed to a natural, unmedicated labor and birth. However, we realize things don’t always go as we

might hope, so most of the following plan assumes everything is going well. We’ll accept alternate interventions

if the midwives or hospital medical staff, in conjunction with us, the parents, deem them to be medically necessary

to preserve the safety of mother and/or baby. Our core goal is a healthy and happy mommy and baby!

Our basic plan is based on the Lamaze Six Healthy Birth Practices:

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Let Labor Begin on Its Own

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Walk, Move Around, and Change Positions Throughout Labor = I want to be able to move as feels best.

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Have Continuous Support = Jason will be the primary support. Our doula, Jill, has great experience and is a

solid, soothing presence. Her suggestions, advice, and assistance will be of great help. I would like privacy and

a minimum of interruptions.

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Coping Tools = I expect I will make noise during labor. Music is very important and a great tool for my relaxation

and focus. Several mood- and tempo-based playlists have been created and loaded into Jason’s iPhone.

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Avoid Interventions That Are Not Medically Necessary = Unless prohibited by strong medical concerns, I want:

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small amounts of food and drink to keep my strength up and to prevent upset stomach

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a minimum of vaginal exams (female practitioners strongly preferred)

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a minimum of monitoring equipment

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please do not offer pain medication

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Avoid Giving Birth on Your Back, and Follow Your Body’s Urges to Push = I may want to give birth in the water,

as long as the midwives deem it to be safe. (We specifically chose this hospital, as it is the only one in the area

where water birth is allowed.) Jason would like to catch the baby, if possible.

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Keep Mother and Baby Together = Baby skin-to-skin on mommy’s chest right after birth, straight to breastfeeding.

Immediate baby care, as per midwives’ suggestions, to include vitamin K shot and eye care after the first breastfeeding

Other notes:

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Our parents live nearby and may come to the hospital during labor. If things are going well, Xiaoling may invite

them into the birthing room. If she gets overwhelmed, we ask that they respect her wishes to swiftly return to the

waiting room. After the baby is born, we will invite them to come in and meet him, but only after completing his

first breastfeeding.

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I tend to go vaso-vagal at blood draws, so, please keep needles to a minimum and help me to lay down with feet

up for blood draws.

Worksheet Template For Preparing Your Birth Plan With Samples Page 6