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Natural Birth Plan Template - Birth Center or Home

birth plan care providers prenatal care Jan 21, 2023

The way in which we are made to feel as we birth our children, sets the tone for the journey of parenthood. Understanding the aspects of the birth process that matter to you the most will support you in cultivating a birth plan or a birth preference sheet that illustrates the specific qualities you wish to integrate into your birth experience. This is an act of honoring ourselves, of weaving a deeper sense of significance to the experience of bringing life into the world. 

 

Natural Birth Plans - Birth Center or Home 

Creating a birth plan gives the people supporting you a guide to inform them as to how to support you in alignment with your desires. If you’re heavily influenced by the language surrounding birth, you may wish to create a birth preference sheet rather than a birth plan. I find that some people feel more flexible in labor with the creation of a birth preference sheet, as the illustration of desires is truly a preference, not a plan. We can plan the container that holds birth, but we cannot plan birth itself. 

When choosing a birth team, I encourage you to be mindful of how they respond to your birth preferences. A response such as, “thank you for sharing this with us,” may help you to feel heard, supported and respected. A care provider, doula or other birth team member who appears to be uninterested in reading your birth plan, may flag a need for you to reevaluate if you want them to be present for your birth. 

A home birth preference sheet normally illustrates instructions on where to find items in the household. This will help support people in navigating your home with more ease, and will reduce any sort of ‘hosting’ duties from falling on you or your support person’s shoulders. In addition, midwives have the capacity to perform a wide variety of medical interventions outside the hospital. For this reason, options for creating preferences within the scope of midwifery are listed below. This natural birth template is also available as an attached downloadable form on this article. 

If you intend to give birth in your home, you may still wish to create a hospital preference sheet, if the need for transfer were to arise. A transfer hospital birth plan should be short and simple, including your preference to consent or refuse certain medications or interventions. If you do transfer to the hospital, it is likely because your care provider believes there is a need for a medical intervention or tool that the hospital can provide. 

If you plan to birth at a hospital or birth center, or you wish to create a transfer birth plan, refer to the hospital birth plan template here: Birth Plan Template - Hospital If you’re interested in my online childbirth class, learn more here: The Comprehensive Guide to Sovereign Birth

 

Natural Birth Plan Template 

 

Name:

Due Date:

Support People: 

Birth Intention: (Peace, Joy, Ecstatic, Gentle, etc)

 

Include as Needed

  • Parking instructions 
  • Location of washing machine and instructions for use
  • Location of cleaning supplies 
  • Location of postpartum meal
  • Location of labor supplies 
  • Location of labor snacks and drinks 

 

Accept/Decline

  • I (accept/decline) the vitamin K injection for my newborn.
  • I (accept/decline) the vitamin K drops for my newborn (you may have to purchase and administer these yourself).
  • I (accept/decline) erythromycin or any antibiotic eye ointment for my newborn.
  • If positive with group beta strep, I (accept/decline) IV antibiotic treatment.
  • I (accept/decline) the placement of an IV port in labor.

 

Preferences for Labor Support (Choose Any)

  • Birth tub
  • Position changes
  • Massage
  • Rebozo 
  • Essential oils
  • Music 
  • Cold washcloths 
  • Birth ball 
  • Shower
  • Birth stool 
  • Doula/support people 
  • Sterile water injections
  • Tens unit

 

Induction (Choose One)

  • If the need for induction were to arise, I prefer to attempt natural labor induction methods on my own, such as caster oil, sexual intercourse, nipple stimulation, homeopathics and position changes.
  • If the need for induction were to arise, I prefer to utilize the medical tools my midwife can provide, such as a membrane sweep.
  • If the need for induction were to arise, I prefer to utilize the medical tools my midwife can provide, such as a membrane sweep or AROM.
  • If the need for induction were to arise, I prefer to attempt my midwife’s suggested form of labor augmentation.

 

Labor Management Suggestions (Choose One)

  • I prefer not to receive suggestions for labor management unless I request them.
  • I welcome suggestions for labor management as support people feel called.

 

Vaginal Exams (Choose One)

  • I prefer not to receive any vaginal exams in labor.
  • I prefer only to receive a vaginal exam in labor per my request.
  • I welcome the use of vaginal exams per my midwife’s recommendation.
  • (Choose one) If I were to receive a vaginal exam, please (do/don’t) share the results (dilation, effacement and station) with me.

 

AROM (Choose One)

  • I decline the use of AROM to induce labor, or during labor.
  • I prefer to avoid AROM, but I will consent to induce labor if needed, or in the presence of a prolonged 1st or 2nd stage of labor
  • I decline the use of AROM to induce labor, but I consent to AROM in the presence of a prolonged 1st or 2nd stage of labor.
  • I accept the use of AROM per my midwife’s recommendation. 

 

Pushing (Choose One)

  • I prefer to avoid directed pushing, and allow for my body to push naturally.
  • I welcome the use of directed pushing in the presence of a prolonged 2nd stage to expedite delivery.
  • I welcome the use of directed pushing per my midwife’s recommendation.

 

Catch (Choose One)

  • I welcome my midwife to catch my baby.
  • My support person wishes to catch my baby with the guidance/support of my midwife if needed.
  • I intend to catch my own baby, if I am able to in the moment.

 

Delivery Location (Choose One)

  • I prefer to deliver in the birth tub. 
  • I prefer to deliver in my (bedroom, living room, etc).
  • I prefer to have the freedom to deliver anywhere I feel the most comfortable.

 

Placenta Delivery (Choose One)

  • I prefer to deliver my placenta on my own, outside the presence of a hemorrhage. 
  • I welcome the use of gentle guidance to assist me in delivering my placenta.
  • I prefer for a provider to wait until I feel cramping sensations before assisting in the delivery of my placenta, outside the presence of a hemorrhage. 

 

Placenta Plan (Choose One)

  • I plan to process and freeze my placenta. 
  • I plan to bury my placenta.
  • I plan for an encapsulation specialist to pick up my placenta. 
  • You may dispose of my placenta. 
  • I am planning a lotus birth, please leave the cord attached.

 

Newborn (Choose Any)

  • Please delay cutting the cord until it is done pulsing. 
  • I am planning to burn the cord, please do not cut it.
  • I am planning a lotus birth, please leave the cord attached.
  • Please leave the vernix on my baby.
  • If my baby if vigorous upon birth, please allow me to stimulate my own baby. 
  • If my baby is in need of respiration support, please offer that support to them while they are on my chest, if possible.
  • We wish for as much privacy and reverence as possible after the baby is born.
  • We intend to have at least one hour of uninterrupted skin to skin time after birth.
  • If I am unable to be skin to skin with my newborn, I prefer for my support person (partner, doula, mother, friend, etc) to hold my newborn skin to skin.

 

Feeding (Choose Any)

  • We intend to breastfeed. 
  • We intend to bottle feed formula.
  • We intend to bottle feed donated milk.
  • We intend to use an SNS system.
  • We welcome lactation support in the presence of feeding challenges. 

 

Hemorrhage (Choose Any)

  • In the presence of a hemorrhage, I consent to the use of all hemorrhage medications including mifepristone, misoprostol and pitocin. 
  • If possible, I wish to attempt the use of pitocin before using mifepristone or misoprostol to control postpartum bleeding.
  • I welcome an injection or IV administration of pitocin immediately after birth.
  • I decline routine use of pitocin for hemorrhage prevention, and only consent to the use of hemorrhage medications in the presence of a hemorrhage. 

 

Episiotomy (Choose One)

  • I prefer to avoid episiotomy, but I will consent to an episiotomy in the presence of an emergency.
  • I decline the use of episiotomy. 
  • I consent to the use of episiotomy per my care provider’s recommendation. 

 

Vaginal Lacerations (Choose One)

  • I prefer to have a vaginal laceration sutured per my care provider’s recommendation. 
  • If the tear is small enough, I prefer to avoid suturing.

 

Tearing Prevention (Choose Any)

  • I (accept/decline) the use of hot compresses to prevent tearing.
  • I (accept/decline) the use of vaginal massage to prevent tearing.
  • I (accept/decline) the use of hands on perineal support to prevent tearing.
  • I (accept/decline) the use of labor and/or delivery in a birth tub to prevent tearing.
  • I (accept/decline) the use of verbal guidance, supporting a slow and controlled delivery to prevent tearing.

 

Other Preferences (Choose Any)

  • I prefer as much privacy as possible.
  • I prefer minimal to no interventions, if possible.
  • I prefer for the room to be as quiet as possible.
  • I prefer for only (blank) visitors in the room at a time postpartum.
  • I prefer no visitors for the first hour postpartum. 
  • I prefer only (blank) visitors in the first hour postpartum. 
  • I prefer to have no one hold my baby aside from (myself/my partner and I) in immediate postpartum. 

 

Notes to include for postpartum

  • I prefer to return to my (bedroom, living room, etc) in postpartum
  • Location for postpartum beverages (teas, broths, etc)
  • Location for postpartum meals 
  • Instructions for supporting the family postpartum
  • Instructions for visitors/limitation of visitors 
  • Preferences for documentation 

 

Image by @whenabellyblooms

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