Name * First Name Last Name Email * Due Date MM DD YYYY Support People Birth Location Home Birth Center Hospital Undecided Care Team Midwife/OB/Doula Environment & Atmosphere Dim lights Candles Music Essential oils Herbal teas/infusions Limited room traffic Quiet voices Blankets Photos from home Intermittent monitoring when appropriate Support person taking photos Birthing ball Other Spiritual/cultural elements to include Scent sensitivites or allergies Labor Preferences Freedom to move (walk/squat/birth ball) Hydrotherapy (shower/tub access) Hands-on comfort (massage/acupressure) Herbal compresses/heat or cool packs Breathwork/meditation/prayer Guided affimations Minimize vaginal exams Limit interruptions; ask before touching Labor discomfort management Unmedicated if possible; I will request if needed Discuss options before offering Epidural on request Open to all recommendations IV medications Induction preferences Prefer to avoid unless medically indicated Open to natural methods first (per provider guidance) Open to medical induction if recommended Birth Preferences Pushing—follow body’s natural urges Cesarean section Pushing—gentle guidance if helpful Immediate skin-to-skin Pushing—change positions freely Delayed cord clamping Partner/support to catch baby (if appropriate) Herbal/ceremonial blessing after birth To view the birth using a mirror To touch my baby's head as it crowns Placenta wishes Encapsulation Keep for ceremonial planting Donate/release to facility Baby Care Initiate breast/chestfeeding ASAP Rooming-in (baby stays with me) No pacifier or formula unless requested Delayed bath Vitamin K Injection Oral (if available/appropriate) Discuss options first Eye ointment Yes Decline Discuss options first Pediatric preferences or provider Postpartum Care Quiet recovery Lowlight recovery Herbal sitz bath/perineal care Warm, nourishing foods & teas Include partner/support in newborn care education Lactation support referral if needed Visitor preferences Immediate family only first 48 hrs By invitation only Open to visitors anytime Notes & Intentions My guiding intention for birth Additional notes or requests Thank you! My Birth Plan