Free Birth Plan Template 38Free Birth Plan Template 38
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DRAFT: 3.31.09

Birthing Plan
This plan can help you consider what will make your birth experience meaningful and comfortable for you.
Please discuss this with your doctor or midwife during your pregnancy. Also, please bring a copy with you to
the hospital when your labor begins.

Basic information
Your name (birth plan for):
Your partner’s name:
Your address:
Your phone:
Name of your labor support person/doula:
Your due date:
Name of your doctor or midwife:
Name of your baby’s doctor (pediatrician):

Labor and delivery: the environment
name

People

role or relationship to
you?

Primary support person
Other people attending the birth

For child visitors:
Would you like the child(ren) present for labor? ˆyes
Should we help you limit visitors?

ˆyes

ˆno

for delivery? ˆyes

ˆno

ˆno

Comfort and mobility
Check all the things you’d like to try during your labor:

ˆ music (please bring your own CDs and player)
ˆ jetted tub
ˆ massage
ˆ TV and DVDs (may bring your own DVDs)
ˆ dimmed lights