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Birth Plan Worksheet  

This Birth Plan Worksheet is designed for use by expectant parents all over the United States. It has a variety of options listed to stimulate research regarding what is available in your community. It is not designed to be printed in its entirity, rather to be used to discuss options with your careprovider.

Need one to print? Click here to print a Birth Worksheet to take to you care provider once you have completed this worksheet!

Birth Place
Hospital Labor & Delivery Area
Birthing Room (LDR or LDRP) Birthing Center

Care Provider
Physician Obstetrician
Family Practice Physician Midwife
Certified Nurse Midwife Lay Midwife

Childbirth Education
Classes at the Hospital Independent Educator
Educator affiliated with physician Lamaze method
Bradley method ICEA
Hypnosis/Hypnobirthing other

Types of Classes
Childbirth Preparation Breastfeeding
Parenting Child Care
Infant/child CPR Sibling Preparation
VBAC (vaginal birth after a cesarean) Cesarean
Teen Childbirth Preparation Teen Breastfeeding

Pregnancy/Birth Support
Husband/partner Sibling of baby
Family members (how many?)_____ Friends
Certified doula/labor support professional  

Oral fluids IV
Saline/Heparin Lock Perineal shave

Comfort Measures
Upright positioning Hydrotherapy (labor tub or shower)
Massage/effleurage Music Therapy
Aromatherapy Breathing Techniques
Active relaxation techniques Heat/cold therapy
Therapeutic touch Reiki
Guided Imagery Acupressure
Squatting Hands/knees position
Birthing Ball  

Assessment of Baby via Heart Beat
Intermittent Auscultation with Stethoscope of Baby's Heart Beat

Electronic Fetal Monitoring



IUPC (intrauterine pressure catheter)

None Relaxants
Local infiltration Regional anesthetics
Epidural Spinal
Paracervical Pudendal
Spinal Narcotic Walking Epidural

None Cervical Ripening Gel
Pitocin Amniotomy
Stripping of Membranes Foley Catheter
Laminaria Tents  

Birth Positions
Squat/using squat bar Hands/knees
Semi-sitting or "C" Sidelying
Sitting with feet in stirrup supports  Birthing stool

Forceps Vaccum Extraction
Perineal Massage (no or minimal episiotomy) Episiotomy

Immediately after birth
Partner cut cord Leboyer birth
Immediate skin-to-skin on mother's abdomen Bonding - skin-to-skin
Breastfeeding Delay of eye ointment

During hospital stay
Rooming-in Breastfeeding
Breastfeeding without bottles, nipples or pacifiers Breast/bottlefeeding
Bottlefeeding Visit from Lactation Consultant
Circumcision Sibling visitation

Going Home
Parent Answer Line Home Care Visit
Lactation Consultant Visit LaLeche League Information

Husband/partner support Husband/partner present during procedure
Anesthesia Options Parent bonding afterwards
Breastfeeding immediately after

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Peanut Ball

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Birthing Balls

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Childbirth Educator Office CD-ROM

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Childbirth Educator Office CD-ROM

Essential forms + curriculum for your childbirth education business with over 50 handouts!

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We will reply as soon as possible. Funding for this site is provided solely by Perinatal Education Associates, Inc. Perinatal Education Associates, Inc. undertake to honor or exceed the legal requirements of medical/health information privacy that apply in the State and Country where this website is located. All content is written by the owners of the site unless otherwise noted.

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