Free Birth Plan Template 43Free Birth Plan Template 43Free Birth Plan Template 43
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Birth Plan:
[ ] Full name:

[ ] Doula:
[ ] Other:

[ ] Partner’s name:

…present before AND/OR
during labor

[ ] Today’s date:
During labor, I’d like:
[ ] Due date: OR Induction date:

[ ] Music played (I will provide)
[ ] The lights dimmed

[ ] Doctor’s name:

[ ] The room as quiet as possible
[ ] As few interruptions as possible

[ ] Hospital name:
Please note that I:
[ ] Have group B strep
[ ] Am Rh incompatibility with baby
[ ] Have gestational diabetes
My delivery is planned as:
[ ] Vaginal
[ ] C-section
[ ] Water birth
[ ] VBAC
I’d like…:
[ ] Partner:
[ ] Parents:
[ ] Other children:

[ ] As few vaginal exams as possible
[ ] Hospital staff limited to my own
doctor and nurses (no students,
residents or interns present)
[ ] To wear my own clothes
[ ] To wear my contact lens the entire
time
[ ] My partner to film AND/OR take
pictures
[ ] My partner to be present the entire
time
[ ] To stay hydrated with clear liquids
and ice chips
[ ] To eat and drink as approved by my
doctor

I’d