Free Birth Plan Template 05Free Birth Plan Template 05
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Birth Plan: Checklist Style
Fill out this page according to your own wishes for your birth. Keep in mind that you might
not be able to follow every wish on this page depending on hospital policy or if complications
arise during your labor. Share your plan with your support team, practitioner, and labor nurse.
My Name: _______________________________________________________________
Due Date: _______________________________________________________________
Labor Companions:________________________________________________________
Healthcare Provider: _______________________________________________________
n I would like as much monitoring as possible.

n Dim Lighting

n Quiet

n I prefer a method that allows me to remain mobile.

n Play Music

n Wear my own clothing

n Fetal monitoring in bed is fine with me.

n Bring things in from home like blankets or photos
n Aromatherapy scents

Pain Relief

n Video/photos taken by______________________

Nonmedical Options