Birth Plan / Preferences Template

Here are suggestions to ensure your list is read and that it builds bridges with the staff (rather than walls) right from the get-go.

It’s nice for the medical staff to read only the things that make you unique. They will tune out and miss the important bits if they’re buried in a long list. If you wish to make a long detailed list for your own process and to facilitate discussion, go for it! But we will suggest edits to create a short document for the medical attendants at your birth.

Layout Basics:

1 page max, large font (12+), lots of white space, 1.25 or double-spaced is nice.
Put it all in one list; some templates separate into “opening”, “pushing” etc. Groan….
List only the birth preferences. Baby/postpartum is another unit with different staff.

Title: Use Wishes, Intentions or Preferences. Avoid Plan.

General Language: Positive and polite. Whenever possible, focus on what you want, rather than what you don’t want. (What do you think of when told “Don’t think of a pink elephant.”?)

Avoid terms that imply granting permission, and phrases such as “unless medically necessary”.

Opening and Closing Statement: If you start with statements that summarize your goals, then you’ll need fewer things on your list. Close with a thank-you statement. Examples are below.

The List: Avoid things that are already standard care. That leaves the impression that you’re demanding or uninformed. Focus on what sets you apart, and on your priorities. Everyone knows you don’t want “this-thing or that-thing unless medically necessary”!

Parent Name(s): Sign / print your name(s) at the end, as a closing.

Midwife or Doctor Signature Line: (Optional) Some people add a place at the end for your medical provider to sign. It shows other attendants that you’ve gone over it.

Template for birth-preferences is offered below. Cut, copy, paste and delete as desired.

____________________________________________________________________________________

(Your Name(s)) Birth Wishes

Highlight any urgent medical info here: e.g. Medical condition, Latex allergy, drug (name it) allergy

Examples of Opening Statements: (This is a sentence / short paragraph to set the tone)

Thank you for being a part of our labour and birth team as we prepare for a natural birth. This sheet expresses our preferences and desires for the birth of our (second) baby.
We would like to share a few things that are very important to us during this special day. Thank you for taking the time to read our birth plan and thank you also for supporting us during this special time!
Thank you for being part of our team as we welcome our baby into the world!
We have heard good things about the (Regina) Hospital staff. Thank you in advance for your hard work, patience and support.
We trust our birth support team and request open lines of communication so we can make well informed decisions if the need arises.
Our wish is for a positive labour and birth experience, with as little medical intervention as possible. A quiet, relaxed atmosphere is our goal.
We have chosen the HypnoBirthing method of a more relaxed, natural birth.
Hello, we are (name) and (name). This is our (first) baby. We’ve chosen to welcome this baby through the Hypnobirthing method of a more relaxed, natural birth. Dim lights, minimum noise and distractions, soft music playing in the background are favored.
I need a safe and supporting environment in which I can surrender, trust and be completely vulnerable. My focus is to be in the moment and fully in my experience. I feel empowered to listen and trust that my body knows what to do.
Do not say or do anything that will take me out of my primal birthing state!
The following is our intention for the birth of our beloved baby. We dream of a loving and peaceful natural birth full of support and respect for our preferences; most of all, a vibrant healthy baby.
The following are our preferred options for a normal labour and birth. We realize that as labor ensues, we may choose to change our thinking and wish to feel free to do so.
We realize that flexibility and a willingness to accept changes to our plan may be necessary.
We’ve planned for a gentle, natural birth. Please discuss any interventions with us.
What follows is a short list of our birth preferences.
This plan is not meant to be rigid. We are happy to change it, after discussion, if the need arises.
Thank you so much for your support. I am happy to discuss, however briefly, any measures which may be deemed medically necessary prior to their implementation.
I wish to be treated respectfully and maintain the autonomy I had before entering the hospital. Before you touch me or intervene in the normal course of my labor/delivery, please discuss it with me and obtain informed consent.
(An example in case of a previously known medical situation with baby) We are aware of and well informed of the baby’s cleft lip and palate. We understand that the first year of our baby’s life will involve a great deal of medical procedures and would therefore like to promote a very gentle entry into his/her new life, with as little interventions and traumatic procedures as possible.
(This is where you might note any special circumstances such as history of trauma or abuse, mobility issues, names of anyone who is not to be at your birth but may try to come in. Use a separate paragraph from your opening statement.)

Choices for Items to Include in Your List: (Include the things important to you.)

Our doula, (name), will support us through our labour and birth.
A nurse familiar with or willing to accept Hypnobirthing strategies.
(for Hypnobirthers) Doctors and nurses: please use words like surge, breathing baby down and waters released instead of the regular words associated with labor.
(Name) is welcome to be with us in the birth room. (Use this for people other than your doula, such as your mother, sister, friend etc.)
(Name) will be supporting us in labour and birth. (No need to list your doula here. This is for other support persons.)
Minimal vaginal exams, and please none performed by a student
Please do not offer me pain medication; I will ask if I’d like this option. We welcome other suggestions of comfort.
Please do not offer pain medication under any circumstances. I will ask if I change my mind.
Relaxation and breathing techniques for as long as possible; then gas and an epidural in that order, if needed.
I will eat and drink as desired.
Intermittent monitoring of the baby’s heart rate in whatever labour position I am in.
If continuous monitoring is medically required, then please use the wireless system so I can move about.
Warm compresses / perineal massage as crowning takes place.
Push instinctively / spontaneously, according to my body rhythms in whatever position feels best. Gentle guidance during crowing is welcomed. I understand “Coached Pushing” is likely necessary in case of epidural.
Mother-directed breathing to ease the baby out.
Please provide a mirror, so I can see the baby’s head.
Dim the lights for the birth.
Room as quiet as possible when the baby is born.
We would be delighted if (name) could catch the baby.
To discover and announce babe’s sex ourselves.
Delay umbilical cord clamping & cutting until cord stops pulsing.
Please leave the cord untouched for (3 minutes/5 minutes/ until placenta is born).
Neither of us wishes to cut the cord.
Ask (partner) if they would like to cut the cord.
We would like (name) to cut the umbilical cord.
Low lights and quiet voices until the placenta is birthed.
Spontaneous delivery of the placenta, and without traction on the cord. Please don’t use medication to accelerate the process.
To be shown the placenta before it is taken away.
We are keeping the placenta.
Please do not touch the umbilical cord until the placenta is birthed.
(Note: If you have any opinions about students, let’s discuss this and create an appropriate line.)

In the event of c-section:

We would like (name of birth partner) and doula to be present in operating room.
We would like (name) to stay with (name) throughout the entire process, including administration of the spinal.
We want to touch the baby as soon as possible.
We would like our family to stay together in the OR and Recovery Room.

Examples of Closing Statements:

THANK YOU FOR SUPPORTING AND HELPING US WELCOME OUR BABY!
We appreciate you taking the time to review and consider our birthing preferences. Thank you.
Thank you in advance for your efforts at our birth.
Thanks for your kindness and co-operation.
Thank you again so much for your help. We really appreciate it!
Thank you so much for being a part of our birth experience!

(Mother name) & (partner name if applicable)

Date: ________________

(Optional:
Doctor / Midwife: _____________________________________ )

“GREY-ZONE” These things are usually standard of care or easy to get. Include them only if you don’t have much on your list, or if you’re very concerned about them and feel better listing them.

A warm, quiet, dimly lit room for labour and delivery.
It’s important that I have freedom of movement and positions at all stages of labour.
Labor to take its natural course without references to “moving things along.”

LEAVE THESE OFF! Most of this is standard of care or only for medical reasons at RGH. If you’re at another hospital, learn their policies and then decide if you need these.

Privacy protected by limiting unnecessary intrusions from strangers.
Move around freely with freedom to change positions and assume labour positions of choice. (standard of care unless a woman has an epidural; then it may not be possible)
Alternatives to medication such as walking, warm water, breathing, and yoga.
Use of the bath / shower.
Access to a birthing ball and mats.
A “no list” of interventions you don’t want i.e. artificially breaking of waters, vacuum, forceps, episiotomy, IV, caesarean birth, internal monitor, induction / augmentation etc. No one wants these things and that is obvious to the staff!
Local freezing for perineal repair.
Baby to mother’s chest immediately after birth.
Baby has skin on skin contact immediately after birth.
Newborn procedures (eye gel, vit-K, weighing etc.) wait until we have time to bond with, and breastfeed, our baby.
If I am unable to be with my baby immediately postpartum, then (partner’s name) holds baby for this critical time.
In the event of c-section mom to breastfeed in recovery room.
Uninterrupted family bonding for at least an hour – we’re in no hurry to have our baby weighed.
If the baby needs to leave delivery room, for (name) to accompany baby at all times.
We are declining eye ointment, per 2015 Canadian Paediatric Society recommendations.
Postpartum mother / baby care is not applicable to birth plans:
- Breast feeding only, no formula at any time without my prior consent (standard care)
- Only I or my partner will bathe the baby, if and when we determine it’s necessary (this will be done routinely at 24hrs in Mother-Baby Unit unless you decline)
- For the baby to be with us at all times – baby/parents rooming in (standard care)
- No Circumcision (Not offered anymore. Parents make private arrangements, pay out of pocket. Never done in Mother-Baby Unit.)