Example of Hospital Birth Plan

This is the Birth Plan that I wrote up for if I needed to be transferred to the hospital during my planned home birth.  I acknowledge that most births are not medical emergencies, but some can become that, so I wanted to be well-prepared.

These were my wishes, based on my own intensified research, but you can of course edit it to suit your wishes!  I hope it helps you!

The following is included: birth_plan.doc


Baby Estimated Delivery Date:



Midwives / Doctor:

Emergency numbers:

After birth:

  • No circumcision (male or female)
  • No Hepatitis B vaccine (we have both been tested negative for Hepatitis B in recent blood tests)
  • No Vitamin K shot (we will do oral vitamin K with our pediatrician)
  • Do not administer antibiotics (I have tested negative for Group B Strep)
  • Do not administer Synagis to our child (whether premature or full-term)
  • No antibiotic ointment in newborn’s eyes (I have tested negative for all sexually transmitted diseases)

If it is medically necessary for me to give birth in a hospital:

  • No Electronic Fetal Monitor unless necessary to save my child’s life
  • I do not wish to receive any induction or pain medication (if you must induce, use Pitocin and NOT Cytotec)
  • Please do not ask me, in the midst of labor, if I want pain medication, I wish to give birth without medication
  • Only test my dilation when I am completely comfortable and ready
  • Do not clamp the cord until after I have birthed the placenta and the cord has stopped pulsing
  • Do not suction my child unless it is necessary to save his/her life
  • Please let my husband announce the sex of our baby
  • Please immediately lay the baby on my chest so I may connect with my baby unless unable to do so for the life of the baby – please check baby while on my chest (see below)
  • We will take the placenta and cord home with us for proper disposal/burial

If it is necessary to save my or my baby’s life and I need a cesarean section:

  • I would like to have a VBAC after this birth, please use a double stitch when repairing my uterine wall and not a single stitch
  • Let my husband announce the sex of our baby
  • Do not clamp the cord until it stops pulsing
  • Do not suction our child unless it is necessary to save his/her life
  • Please allow my husband to hold our baby until the placenta has been detached – please check our baby while in his arms
  • Please let me have my baby on my chest after the placenta has been detached and delay after-birth procedures (see below)
  • We will take the placenta and cord home with us for proper disposal / burial

After vaginal or cesarean birth:

  • Please let us hold our baby and delay washing, weighing, stamping our baby so we can be with him/her for those first precious moments
  • My blood is NEGATIVE and my husband’s POSITIVE. Please test my baby’s umbilical cord to determine if s/he is a Rh+, to see if I need or do not need Rhogam. (I will request the no mercury Rhogam, BayRoh-D, from Bayer Pharmaceuticals.)
  • Do NOT give a Hepatitis B shot
  • Do NOT give a Vitamin K shot (we will do oral Vitamin K with our pediatrician)
  • Do NOT put antibiotic ointment in his/her eyes (Amy has tested negative for all STDs, to include gonorrhea and chlamydia)
  • We do not consent to any Synagis for our baby
  • You MAY give our baby a PKU test after several hours of life, while in my arms (after he/she is warm and ready and I may nurse right after)
  • Do not wash our baby; I will clean him/her with a damp (NO SOAP) washcloth
  • I will be BREASTFEEDING; please do not bottle feed my baby ANY formula or use ANY bottle and DO NOT give a pacifier
  • Please leave our baby in our room at ALL TIMES
  • Please do not let me sleep when my baby is hungry, I would like to exclusively breastfeed
  • Do not take our baby out of my room without my or my husband’s knowledge and/or permission
  • Our son will NOT be circumcised; we wish to keep his penis intact


4 thoughts on “Example of Hospital Birth Plan

  1. You are one smart cookie! I am going to have my fourth baby soon and I don’t know about a lot of this stuff! Thanks for your lovely comments! I love reading about pregnancy and delivery! I just posted about week 34 today.

  2. My husband and I are learning about all the changes hospitals have taken over the last 30 years when it comes to births. I tried to explain some of the changes to my mom and she told me to stop because she couldn’t keep up. Crazy right?! Thank you for giving an example of a real (natural) birth plan! We will be researching all of our choices as we start our family.

    • I’m so happy that my research could help you! It is so important to be informed — because as mamas, in the labor state, we are hardly in a condition to express our wishes! These are our babies and we have a right to what happens to them <3

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