Leanna Mae's birth plan fill-in form

Hi! I’m Leanna Mae. I’m an author, women’s health educator, and birth doula in Ohio. I teach a class on birth plans. This fill-in birth plan is from chapter 6 in my let’s talk birth plans class. At this point in class, most students have decided where they are giving birth, what kind of provider they want, and the practice they’ve chosen. In chapter 3, we have discussed all the different options and routine/common interventions they may be offered. Chapter 6 is about summarizing your goals.

birth plan fill-in form

$10.00

Add to cart

This birth plan is for filling in a written summary of your preferences and how you feel on these options. This is for the parents to help them draft and decide their choices. You can also share this with your doula. I want you to write how you feel about each of these things. What are you okay with and not okay with? You are filling in the blank spaces with the choices/preferences that are right for you. There are no checkboxes or cookie cutters here. This birth plan is uniquely for you. Make your own recipe.
 
Yes, it is a few pages long with all the blank spaces to write. If I am your doula, I am willing to read every word you write. It is important to me to know what’s important to you, what matters most to you, what you’re okay with, and even what you’re nervous about. A birth plan like this is a great communication tool. I want to know how you feel about these options.
 
This is not the birth plan you’ll give your doctor or midwife and L&D nurse. For the medical staff, it’s best to do a condensed version that is one or two pages.
 
In the blog, I will explain what I want to know and sometimes why I want to know that under each section.
 
Feel welcome to download your own copy (for individual use only) of the fill-in birth plan form.

Know before you go

Here are a few things to have planned that aren’t usually discussed in birth plans. Don’t forget about pet care and backup transportation plans. This section is self-explanatory.
 

• Childcare arrangements while you are at the hospital or birthing center:
• Pet care arrangements:
• Do you have anyone to watch your home for you?
• Transportation plans for when you’re in labor and headed to the maternity center:
• Who do you want at the birth?
• List your birth team. For example: provider, doula, birth photographer…

Your fill-in birth plan for you and your doula to discuss

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. Tell us what is most important to you.
 
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 autonomy is what you want most, tell us. If encouragement is what you want most in regards to support, let us know that so we can do our best to be what you need.
 
Is there anything that you feel very strongly against?
This is something I really want to know. If there’s anything you feel strongly against, please make a note of it. You can provide context if you want to or just highlight it.
 
What about strongly in favor of? I want to know anything that you feel really strongly about.
If there’s anything you very much want or feel strongly in favor of, let me know that too. I pay attention to those things and do my best to support you.
 
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. It’s also something we can work on prenatally. Is there any education I can provide that will help you understand the topic better? Is it something you need to talk through? Knowing any fears – especially big ones – is helpful for me as a doula and also for your medical care team.
 
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. If you are in recovery from drug use, please tell me that before we’re in a situation that you’re being offered drugs that could lead to relapse. Is there anything that you want your doula or staff to know about?
 
 
STAGE 1: Labor
 
Induction – How do you feel about elective induction? Sometimes inductions are medically necessary and the best way to have a healthy outcome. If induction is not needed, write down how you feel about it. Do you want to avoid induction? Or schedule that birthday party?
 
Induction method if you do get induced – If you do need to or choose to get induced, do you have a preference on the method? Anything you want to avoid? Or something you prefer to try first? Have you asked your chosen hospital what options are available for cervical ripening?
 
Pain management – Do you want to go unmedicated? Or do you want the epidural? Some locations also offer laughing gas or IV pain meds. How strongly do you feel about those preferences? Have you chosen your doula yet?
 
Movement and positioning – Freedom to move is standard practice nowadays; still tell me your thoughts on this.
Do you have anything specific in mind that you want to make sure is offered or supported? In your own words, what are your plans for this during labor?
 
Monitoring and assessing progress – We talked a lot about this earlier in the birth plan class. We talked about things like monitoring baby’s heart (continuous, wireless, or intermittent with a doppler), cervical exams to assess labor progress, and how momma will be monitored. How do you feel about all that? Do you prefer continuous monitoring or intermittent? Minimal exams?
 
IV or saline lock – A saline lock is a common alternative to routine IV fluids. Saline locks have become mainstream in many places.
 
Augmentation – We talked a lot about how labors can be sped up or revved up a bit if things aren’t progressing well. How do you feel about Pitocin? Do you prefer non-medicinal ways to strengthen contractions?
 
Medications – Do you have any preferences on medications in labor? If you are GBS+, do you plan to do the antibiotics to prevent infection?
 
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 – There are different types of hospital beds that may be available in labor and delivery. Waterbirth is available in some hospitals and birthing centers. Some facilities also have birth stools.
 
Position if you have a preference for or against – Do you have a preference on what position to be in for delivery? Or a position you do not want to be in? Changing positions throughout delivery can help bring the baby down.
 
Pushing – Do you want the staff to direct your pushing or leave you be? Any thoughts on pushing techniques or breathing techniques?
 
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 if needed – 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 want or don’t want for delivery, make a note.
 
 
STAGE 3: Delivery of the placenta (afterbirth)
 
Medication – Do you want routine Pitocin to prevent postpartum hemorrhage?
 
Cord clamping – How long do you want to wait? If you have a preference beyond what is standard practice at your chosen facility, be specific.
 
Cord cutting/burning – Who do you want to cut the cord?
 
Placenta – Are you planning to do anything with the placenta afterwards? Or do you want to see it before they take it?
 
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 pretty standard now. Any preferences on this?
 
Vernix – Do you want to rub in the vernix?
 
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 in some facilities.
 
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 – Erythromycin ointment and the vitamin K shot are routine. As of current, the Hepatitis B vaccine is also routine. How do you feel about each of those? You can opt in or opt out.  
 
Circumcision – What are your plans for circumcision if you are having a son?
 
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, it’s good to have a just in case plan for a surgical birth. What do you want us to know about supporting you through a c-section? How do you feel about the idea of having a c-section? It’s helpful to let your doula know that.
 
 
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 rundown of the fill-in birth plan I give my students and clients. Download your copy today.