Birth Matters! Series / Birth Plan Resources / Resources

Sample Birth Plan 1

Joy and Jack’s Birth Plan

Joy and Jack Doe
Due Date: March 18, 2016
Birth Facility: Johnson Hospital
Doctor: Dr. Gordon
Pediatrician: Dr. Scott

This is our second child, and we are planning for a natural birth experience. Our first baby was delivered vaginally with no complications. We have taken independent childbirth classes and have prepared as much as possible for this birth. We have hired a doula to attend our birth. Joy’s mother will also be present.


We would like a quiet and dim labor environment with limited strangers and visitors (no residents please). Joy would like to wear her own clothes during labor.

Joy would like to be allowed to drink clear fluids during labor.

Joy does not want pain medication. Please do not offer an epidural or pain medication unless she asks for it.

Joy plans to handle any pain during labor in the following ways:

– Walking, Movement, Changing Positions
– Music / Relaxation MP3
– Water (shower, tub)
– Breathing
– Heating Pad
– Massage

Medications / Procedures

We request intermittent fetal monitoring or doppler fetal monitor if one is available.

Joy would like to avoid medications and added procedures when possible. If interventions are necessary, we would like to discuss all options with our doctor and request the right to accept or deny any interventions unless it is an emergency.

We request that an IV only be placed if necessary.

We request that no episiotomy be performed, and that the mother is allowed to tear naturally.

Joy would like to avoid a catheter and instead be allowed to use the restroom throughout labor.

If induction seems necessary, we prefer to try natural induction methods before using medical induction.

Cesarean Section

If a cesarean section seems necessary, we would like to obtain a second opinion from another doctor.

If a cesarean section is needed, we would like:

– Jack to be present
– Joy to remain awake and to see baby immediately following delivery
– Joy be allowed to breastfeed as soon as possible

We would like baby to be placed directly onto mom’s chest and that any vital signs be taken from there unless there is an emergency. Joy wants to breastfeed as soon as possible after the birth. We request that the placenta be delivered naturally, unless there is an emergency.

We would like to decline:
– any shots/vaccinations
– supplementation
– pacifier / artificial nipples

If there are complications or procedures that need to be done on our baby, we request that our pediatrician be contacted immediately and that we be consulted first.

If the baby is a boy, he will NOT be undergoing a circumcision.

We would like to “room in” with baby
Thank you all who will help us in making this a wonderful experience!

Doctor’s signature:


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