Leanna Mae's birth plan fill-in form

Hi there. I’m Leanna Mae. I’m an author, maternal-infant wellness educator, birth doula, and lactation specialist. I’m also a big fan of birth plans because they are an excellent tool to have notes on what my students/clients want for their birth experience and maternity care. This is the birth plan fill-in form that I use with my doula clients and give to my students. Download the form below.

birth plan fill-in form

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In the blog, I will explain what I want to know and sometimes why I want to know that under each section. Those notes will be written in gray to make it a little easier to see what’s on the actual form (black ink).

The birth plan fill-in form

Write your overall birth goals in this section.
This is something I like having on the first page. As soon as I look at your birth plan, I want to be reminded of what your goals are. I think this paragraph is a good introduction, at least for me as a doula.
 
What are you looking forward to the most? What are you most excited about?
I love to know what families are most excited about. It’s helpful to me to know what those really special things are for them so I can do my best in a support role to help them get that, and also take pictures of those moments for them.
 
How can your care team help you have the health care and birth experience that you want?
I really want to know what you want from your care team. What kind of care are you looking for?
 
If you will, share any fears you have. You can communicate these with your care team.
This is something that is so helpful to me. It helps me know what to watch for to prevent those fears or help you navigate them with additional support. It gives me a better idea of what kind of support people need.
 
Write any notes of special importance in this section.
If someone is a survivor of domestic violence or assault or any kind of trauma, if they’re comfortable sharing that with me here is a place to note that. If a birthing woman does not want any males in the room, let me know here. If this is a rainbow baby or it took a long journey of infertility to get here, these are things to note.  
 
STAGE 1: Labor
 
Induction –
How do you feel about induction? It is commonly recommended. Make a note of your preferences on it.
 
Induction method if we do induce –
Do you have a preference for what you want or don’t want if you do go the induction route? If you have strong feelings about this, let me know.
 
Pain management –
What are your pain management plans and how strongly do you feel about that?
 
Movement and positioning –
Do you have anything specific in mind that you want to make sure is offered or supported?
 
Augmentation –
How do you feel about speeding labor up? Naturally? With medicine or interventions? Is there anything you definitely don’t want? Is there an approach you would prefer?
 
Monitoring and assessing progress –
Are you okay with continuous electronic fetal monitoring or do you prefer doppler if heart tones are good? Or do you prefer fetoscope if this is a home birth?
 
Medications –
What are your thoughts on routine medications and IV fluids?
 
Food and drink –
How do you feel about hospital policies that don’t support eating in labor? Do you plan to bring your own snacks and drinks?
 
Environment –
This one is important to me as a doula because part of what a doula does is try to nurture the environment the birthing mother wants.
 
STAGE 2: Delivery of the baby
 
Intended place of delivery –
Do you want a waterbirth? Do you think you’ll be most comfortable in bed? Do you want to try a cub or birthing stool?
 
Position –
Every provider has their standard preference and it’s often mom on her back with legs up. Are you okay with that? Do you want to deliver in an upright position? Do you want to birth how your body leads you?
 
Pushing –
Do you want the staff to direct your pushing or leave you be?
 
Episiotomy –
Is this something you are okay with at your provider’s discretion without consent or do you require consent? Or are you not okay with this intervention at all?
 
Instrument assistance –
Do you have any preferences on this?
 
Who catches –
Would you like your husband to catch? Would you like assistance in pulling your baby out yourself?
 
Other notes on delivery –
If there’s anything else you have plans on for delivery, let me know!
 
 
STAGE 3: Delivery of the placenta (afterbirth)
 
Medication –
Sometimes mommas don’t want the standard meds given routinely for stage 3. If you don’t, this is something you need to make known.
 
Cord clamping and cutting –
What is your stance on delayed cord cutting? How long do you want to wait?
 
Placenta –
Are you planning to do anything with the placenta afterwards?
 
Other notes on stage 3 –
Is there anything you want or don’t want regarding the delivery of the placenta?
 
Neonatal care
 
Skin to skin –
Skin to skin is often a goal. Do you want your baby to stay on you as much as possible?
 
Golden hour –
Have you thought about visitor restrictions in the first hour or so after birth?
 
Feeding –
Are you planning on breastfeeding? How long? Are you planning on formula feeding? Do you have a plan for which formula to use?
 
Separation –
If you don’t want baby to be taken out of the room without a parent, let them know. It’s common to take baby to a separate room for things like the hearing test.
 
Bathing –
Delaying the newborn bath is becoming common practice. How long do you want to delay? Do you want the nurse to bathe or one of the parents?
 
Testing –
Is there anything you want to do differently with the standard testing such as the metabolic screening?
 
Medications –
Any notes on this? For example, if you don’t want to do the eye ointment or certain shots, note that here.
 
Circumcision –
What are your plans for circumcision if you are having a son? Note: This generally only applies to American readers. The U.S. is the only country in the world that does routine infant circumcision. It’s actually illegal in some countries.
 
Other special instructions regarding baby care –
Things that could go here would be things like plans to cloth diaper in the hospital.
 
In case of c-section
No matter how much a momma wants a natural birth, I do want her to have some back-up plans in case birth takes a different route.
 
OTHER NOTES
Is there anything else you want to note for your care team? It could be things like “no students” or letting them know you have a birth photographer.
 
There you have it. That’s a quick run down of the fill-in birth plan I give my students and clients. Download your copy today.