One Page Birth Plan

Prepared by: [YOUR NAME]

Contact Email: [YOUR EMAIL]

I. Personal Information

Parent Details
Name	[PARENT'S FULL NAME]
Partner’s Name	[PARTNER'S FULL NAME]
Due Date	[DUE DATE]
Obstetrician/Midwife	[OBSTETRICIAN/MIDWIFE'S NAME]
Birth Location	[HOSPITAL/BIRTH CENTER/HOME]

II. Labor Preferences

A. Environment

Lighting Preferences: Dim / Natural Light / Bright
Sound Preferences: Silence / Music / White Noise
People Present: Partner, Doula, Family Members, Friends (Specify Names)

B. Pain Management

Preferred Methods:
- Breathing Techniques
- Hypnobirthing
- Epidural
- IV Pain Medication
- Nitrous Oxide
- Other: [SPECIFY OTHER METHODS]

C. Movement and Positioning

Freedom to Move: Yes / No
Preferred Positions: Walking, Squatting, Sitting, Birthing Ball, Hands and Knees
Use of Birthing Aids: Birthing Ball, Squat Bar, Other: [SPECIFY OTHER AIDS]

III. Delivery Preferences

A. Pushing

Pushing Preferences: Spontaneous / Directed
Use of Mirror: Yes / No
Episiotomy: Prefer to avoid if possible / Acceptable if necessary

B. Interventions

Induction Methods: Natural methods preferred / Medical induction if necessary
Assisted Delivery: Avoid if possible / Use Forceps / Vacuum Extraction if necessary
Cesarean: Avoid if possible / Planned / Open to C-Section if medically indicated

C. Immediate Post-Birth

Skin-to-Skin Contact: Immediate / After Initial Cleaning
Umbilical Cord: Delayed Clamping / Immediate Clamping
Cord Blood Banking: Yes / No / Undecided

IV. Postpartum Care

A. Baby Care

Feeding Preferences: Breastfeeding / Formula / Combination
Rooming-In: Yes / No / Partial
Pediatrician: [PEDIATRICIAN’S NAME]
Vaccinations: Follow Standard Schedule / Selective / Delayed

B. Parent Care

Pain Relief: Request options / Minimal pain relief preferred
Visitation: Open to visitors / Limited visitation / No visitors

V. Special Considerations

Religious or Cultural Preferences: [SPECIFY RELIGIOUS]
Allergies or Medical Conditions: [LIST ANY KNOWN ALLERGIES]
Other Important Information: [ANY OTHER IMPORTANT INFORMATION]

VI. Conclusion

We appreciate your attention to our birth plan and your commitment to supporting us during this significant time. Your understanding and cooperation in adhering to our preferences contribute to creating a positive and safe birth experience for both us and our baby. If there are any questions or concerns, please feel free to reach out to us.

Thank you for respecting our birth plan and supporting us through this special time. Our goal is a safe and positive birth experience for both the baby and the parents.