The Birth Plan
Template
FOR COUPLES
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Introduction
How is it that pregnancy feels so long and so short, all at once?
You’re probably busy checking off all your to-do lists to prepare for your
baby, but have you thought about what you want for your birth?
One of the best ways to prepare for your birth is with a birth plan. Actually, we call our birth
plans “Birth Wish Lists.” Here’s why: it’s really important to plan for your birth, but it’s equally
important to hold those plans lightly. Birth is unpredictable, and in our experience, couples
who hold onto their plans tightly often end up disappointed.
As you fill out your Birth Wish List, you may realize that there are some things you don’t know
about. That’s fine! We highly recommend that you sign up for our Birth Class for Couples to
get educated about all the things on your Birth Wish List.
You may be thinking, “I’ll just Google it.” However, most of the sources you’ll read on Google
are either very general or very biased. In our birth class, we literally take scientific studies
and break them down for you so you can understand why you would want something (like IV
fluids) and why you wouldn’t. We don’t tell you what to do; we give you the pros and cons of
everything so you’re empowered to make decisions with confidence as your birth unfolds.
We don’t stop with just a Birth Wish List, though. In this document you’ll also find a Birth Plan
for Partners. We call this one a “plan” because it outlines exactly how your partner will support
you during all stages of your birth. Without a plan, your partner may feel like a deer in the
headlights once labor begins!
This isn’t a document you’ll hand to your provider, although you should print it off and bring it
with you in your hospital bag. In fact, you should also print off the Birth Wish List and bring a
few copies in your hospital bag, too. Your partner will be able to reference both to support and
advocate for you.
As you go through our birth class, you’ll have opportunities to learn about your birth options,
decide what type of birth you want and discuss all of this with your partner during our “Turn
and Talks.” You’ll also get to learn about all the ways your partner can support you and practice
natural pain relief methods and positions so you’re ready for the big day.
Once you fill out both the Birth Wish List and the Birth Plan for Partners, you’ll feel so
prepared for your birth. You’ll have a plan A, B and C, and your partner will be ready to support
you all along the way.
We wish you all the best as you welcome your new baby into the world!
Birth Wish List
Personal Information:
Mom’s Full Name: Doctor’s Name:
Partner’s Full Name: Hospital Name:
My desired birth is a:
Vaginal unmedicated birth Vaginal birth with epidural VBAC C-section
People I want in the birthing room with me:
Health Information
I have Group B Strep Other complications:
I am Rh Negative Allergies:
During labor I would like:
Music To wear my own clothes Labor in water
Dim lights To eat and drink No IV fluids
Minimal cervical checks Suggestions for labor positions Hep or Saline lock
No students Use of birth and peanut ball As few interruptions as possible
Suggest labor positions Labor out of the bed and walk My support person to be
according to baby’s station the halls present the entire time
Fetal monitoring I prefer:
Continuous monitoring Intermittent monitoring Wireless monitoring
BIRTH WISH LIST 01
For pain relief, I want:
No epidural. Please do not offer one. Aromatherapy
An epidural during active labor Counter pressure
An epidural ASAP IV pain medication
A light or walking epidural Nitrous Oxide
TENS Sterile water injections (if available)
To labor in the tub or shower Emotional support & encouragement
Massage
During the pushing stage, I want:
To be in water Open-glottis pushing
To f reely choose my position, preferably upright Push without time limits as long as baby
and I are healthy
Coaching on how to push
No episiotomy unless absolutely necessary
Perineal massage while crowning
Avoid vacuum/forceps
Warm compresses
Let my partner catch the baby
Hands-off delivery
Immediately after birth, I want:
Delayed cord clamping Pitocin only if needed
Delayed cord clamping until cord stops pulsating Standard Pitocin administration
Partner to cut the cord To deliver the placenta spontaneously
and without assistance
To bank cord blood
No Pitocin
If a c-section is needed, I would like:
To try everything possible to avoid it f irst To pull the drape down so I can see what
is happening
My partner to be in the room with me
The surgery to be explained to me as it’s
To try skin to skin in the OR happening
My partner to hold our baby as soon as possible To breastfeed ASAP, preferably in the PACU
BIRTH WISH LIST 02
I would like to:
Do skin to skin ASAP and uninterrupted See a lactation consultant ASAP
Suctioning & assessment done on my chest if possible Have my baby boy circumcised
Delay all procedures for the f irst hour or two Bathe my baby at home
Room in with my baby Bathe my baby at the hospital
I plan on feeding my baby: I do not want my baby to have:
Breastmilk only A bottle
Breastmilk only (via breast pump) A pacif ier
Breastmilk and formula Vitamin K
Formula only Erythromycin ointment
Hepatitis B vaccine
Formula
Other:
BIRTH WISH LIST 03
Birth Plan for Partners
*This is not meant to be given to your provider! This document is
for you and your partner to discuss his role during your birth and
to have a plan for how to utilize him and care for his needs, too.
During early labor, I will:
Notify the provider that labor has begun Time contractions
Clean the house Provide emotional support
Make mom a nutritious meal Provide physical support (list preferred methods)
Arrange childcare (if applicable)
Distract mom as long as possible
During active labor, I will:
Create a calm environment Speak aff irmations
Reminder her to relax Advocate for mom’s birth desires
Model breathing techniques Help mom push through if she doesn’t want an epidural
Provide continuous physical support Feed mom small snacks and ensure she’s drinking fluids
Provide emotional support Help mom to the bathroom regularly
Help mom make decisions Provide family and f riends with updates
Help mom into different positions
If I need a break, I will: During the pushing phase, I will:
Ask for another family member Provide emotional encouragement
or f riend to take over for me
Ground mom if she feels like giving up
Ask the nurse to take over for me
Help mom into different positions
Ask the doula to take over for me
Catch the baby if possible
Stay in the room, but have someone bring
me food/drink Cut the cord
During the first 24 hours, I will:
Stay with our baby during tests & if additional care Advocate for mom and baby’s needs
is needed
Communicate with family & friends about the birth
Order mom a meal
Schedule visitors
Do skin to skin after mom
Usher visitors out of the room if mom needs sleep
Soothe baby so mom can rest, if appropriate
BIRTH PLAN FOR PARTNERS 04
