Birth Plan Template for Obstetric Patients
Use this comprehensive birth plan template to facilitate shared decision-making conversations with your patients, documenting their preferences while maintaining flexibility for the unpredictable nature of childbirth. 1
Patient Demographics & Medical Information
Basic Information
- Patient Name: _________________
- Date of Birth/Age: _________________ 1
- Height: _______ cm 1
- Pre-pregnancy Weight: _______ kg 1
- Estimated Due Date (EDD): _________________ 2, 3
- Current Gestational Age: _______ weeks _______ days 1
- Obstetric Provider: _________________ 4
Obstetric History
- Gravidity: _______ 1, 4
- Parity: _______ 1, 4
- Previous Pregnancy Outcomes: 1
- Live births: _______
- Pregnancy losses: _______
- Gestational age at delivery: _______
- Previous Cesarean Delivery: ☐ Yes ☐ No 1, 4
- If yes, number: _______
- Previous Preterm Births: ☐ Yes ☐ No 1
- Previous Congenital Malformations: ☐ Yes ☐ No 1
Medical Conditions
- Hypertension: ☐ Yes ☐ No 1, 4
- Diabetes Mellitus: ☐ Yes ☐ No (Type: _______) 1, 4
- Renal Disease: ☐ Yes ☐ No 1
- Thyroid Dysfunction: ☐ Yes ☐ No 1
- Antiphospholipid Syndrome: ☐ Yes ☐ No 1
- Previous Thromboembolic Events: ☐ Yes ☐ No 1
- Other Medical Conditions: _________________ 4
Current Pregnancy Information
- Singleton/Multiple Pregnancy: ☐ Singleton ☐ Twins ☐ Other 1
- Current Medications: _________________ 1, 4
- Allergies: _________________ 1
- Blood Type & Rh Status: _________________ 5
- Group B Streptococcus Status: ☐ Positive ☐ Negative ☐ Unknown 1
Labor Preferences
Birth Environment 1
- Preferred Labor Room Setting:
- ☐ Dimmed lighting
- ☐ Music (specify type: _______)
- ☐ Aromatherapy
- ☐ Privacy/minimal interruptions
- ☐ Other: _________________
Support Persons 1
- Primary Support Person: _________________
- Additional Support Persons: _________________
- Doula: ☐ Yes ☐ No (Name: _______)
- Photography/Video: ☐ Yes ☐ No
Labor Course Preferences 1
Mobility During Labor:
- ☐ Freedom to move/walk
- ☐ Use of birthing ball
- ☐ Use of shower/tub
- ☐ Position changes as desired
Eating/Drinking During Labor:
- ☐ Clear liquids as desired
- ☐ Light snacks if appropriate
- ☐ Ice chips only
Labor Augmentation: 1
- ☐ Prefer to avoid amniotomy unless medically indicated
- ☐ Prefer to avoid oxytocin unless medically indicated
- ☐ Open to interventions as recommended
Pain Management Preferences
Note: Birth plans should remain flexible as pain management needs may change during labor. 1
Non-Pharmacologic Methods 1
- ☐ Breathing techniques
- ☐ Position changes
- ☐ Hydrotherapy (shower/tub)
- ☐ Massage
- ☐ Heat/cold therapy
- ☐ TENS unit
- ☐ Other: _________________
Pharmacologic Methods 1, 6
Epidural Analgesia:
- ☐ Prefer to avoid initially, try non-pharmacologic methods first
- ☐ Request when needed
- ☐ Request early in labor
- ☐ Decline
Other Medications:
- ☐ IV narcotics if needed
- ☐ Nitrous oxide if available
- ☐ Other: _________________
Fetal Monitoring Preferences
Monitoring Method 1
- ☐ Intermittent auscultation (if low-risk)
- ☐ Continuous electronic fetal monitoring
- ☐ Wireless/telemetry monitoring if available
- ☐ Provider's recommendation based on risk factors
Delivery Preferences
Delivery Position 1
- ☐ Semi-recumbent
- ☐ Side-lying
- ☐ Squatting
- ☐ Hands and knees
- ☐ Provider-guided based on circumstances
- ☐ Other: _________________
Perineal Management 1, 6
Episiotomy:
- ☐ Prefer to avoid unless medically necessary
- ☐ Provider's discretion
Perineal Support:
- ☐ Warm compresses
- ☐ Perineal massage
- ☐ Provider's standard technique
Cesarean Delivery (if indicated) 1, 4
- Support Person Present: ☐ Yes ☐ No
- Clear Drape (if available): ☐ Yes ☐ No
- Skin-to-Skin in OR (if stable): ☐ Yes ☐ No
- Music in OR: ☐ Yes ☐ No
Umbilical Cord Management
Cord Clamping 1
- ☐ Delayed cord clamping (30-60 seconds minimum, if infant stable)
- ☐ Immediate clamping if medically indicated
- ☐ Partner to cut cord: ☐ Yes ☐ No
Cord Blood 1
- ☐ Cord blood banking (private)
- ☐ Cord blood donation (public)
- ☐ No cord blood collection
Newborn Care Preferences
Immediate Newborn Care 1
Skin-to-Skin Contact:
- ☐ Immediate and uninterrupted (if stable)
- ☐ After initial assessment
First Bath:
- ☐ Delay until after first breastfeeding
- ☐ Delay 24 hours if possible
- ☐ Standard timing
Feeding Preferences 1
- ☐ Exclusive breastfeeding
- ☐ Breastfeeding with formula supplementation if needed
- ☐ Exclusive formula feeding
- ☐ Donor milk if supplementation needed
Newborn Procedures 1
- Vitamin K: ☐ Accept ☐ Decline
- Erythromycin Eye Ointment: ☐ Accept ☐ Decline
- Hepatitis B Vaccine: ☐ Accept ☐ Decline ☐ Delay
- Circumcision (if male): ☐ Yes ☐ No ☐ Undecided
Newborn Rooming 1
- ☐ Rooming-in 24 hours
- ☐ Nursery care at night
- ☐ Flexible based on recovery needs
Postpartum Care Preferences
Immediate Postpartum 1
Placenta Delivery:
- ☐ Physiologic (spontaneous)
- ☐ Active management with oxytocin
- ☐ Provider's standard practice
Postpartum Medications:
- ☐ Routine oxytocin for hemorrhage prevention
- ☐ Pain medication as needed
- ☐ Stool softeners
Recovery Preferences 1
Visitors:
- ☐ Immediate family only initially
- ☐ Limited visitors
- ☐ No restrictions
Hospital Stay:
- ☐ Standard length (vaginal: 24-48 hours; cesarean: 72-96 hours)
- ☐ Early discharge if appropriate
- ☐ Extended stay if needed
Contraception Planning 4
- ☐ Discuss postpartum contraception
- ☐ Immediate postpartum LARC placement
- ☐ Prescription at discharge
- ☐ Discuss at postpartum visit
- ☐ Not interested at this time
Special Instructions or Considerations
Cultural/Religious Preferences 1
Special Circumstances 1
- ☐ Life-limiting fetal diagnosis
- ☐ High-risk maternal condition
- ☐ Other: _________________
Additional Notes 1
Acknowledgment & Flexibility Statement
I understand that this birth plan serves as a guide for my preferences and does not guarantee specific outcomes. I acknowledge that medical circumstances may require changes to this plan, and I trust my healthcare team to make decisions in the best interest of my health and my baby's health. 1
I understand that having a birth plan may be associated with decreased rates of epidural use, amniotomy, and oxytocin augmentation, as well as potentially lower cesarean delivery rates, but that these interventions may become medically necessary. 1, 6
Patient Signature: _________________ Date: _________________
Provider Signature: _________________ Date: _________________
Date Birth Plan Discussed: _________________
Follow-up Discussion Date (if needed): _________________
Provider Notes
This section is for provider documentation of birth plan discussion, including any preferences that may not be achievable at this facility or any medical contraindications to patient preferences. 1