Birth Preferences Template

See the Google Docs template linked here.

1. Open the link

2. Select File > Make a Copy

3. Once you have made a copy, it will open in a new tab

4. Once you have made your copy, rename your file with your name or initials

5. Click File > Share > Share with Others > copy and paste my email to share with me: info@magdalenadoula.com

Instructions for Birth Preferences Template

In the About Me section, fill in your name, and the first names of the people who will be with you during your labor and birth as well as their relationship to you under birth team. 

Example: Alex (partner), Jane (sister), Magdalena (doula)

For your birth goals, keep it short and sweet. Think of it like the thesis of your birth plan. Feel free to copy and paste any of the following: 

• An unmedicated, physiologic birth, minimizing interruptions and interventions if safe. 

• An informed and positive experience, with use of an epidural when requested. 

• A birth that prioritizes trauma informed care, informed consent, autonomy, and respectful maternity care.

• My priority is a peaceful, calm experience if everything is unfolding normally. 

• My priority is to utilize movement as much as possible in labor. 

• Or come up with your own!

In your health and personal history, write if you have any medical conditions with this pregnancy, any prior births, or allergies. 

In the Labor section of your plan, there are three parts:

For atmosphere, describe how you want the birth room to feel: dim lighting, soft voices, minimal interruptions, etc. 

For fetal monitoring, you can copy and paste any of the following: 

• Intermittent auscultation, or Bluetooth monitoring if continuous monitoring is necessary to prioritize my ability to move 

• Bluetooth monitoring

• Intermittent auscultation before utilizing an epidural, and standard monitoring after

• Standard continuous monitoring

For pain management, list any tools that require staff involvement and your general idea for labor, examples: 

• Unmedicated birth, utilizing the shower, TENS unit, and other comfort measures 

• Nitrous oxide, shower, TENS unit, sterile water injections

• Utilize shower, TENS unit, and other tools before using an epidural

• Epidural as soon as possible 

For pushing and birth, list any of the following things that are important to you: 

• I would like to wait until I feel the urge to push

• Utilize different positions for pushing

• To give birth upright 

• Warm compresses to be held on my perineum during crowning 

• Mineral oil 

• Use of a mirror 

• To touch baby’s head as they crown

• I would like to catch my baby 

• My partner would like to catch our baby

Under immediate postpartum, be sure to note how long you would like to delay cord clamping for, ex: 

• I would like to delay cord clamping for 2 minutes 

• I would like to delay cord clamping until the cord stops pulsating

• I would like to delay cord clamping until the cord is flat and white

• I would like to delay cord clamping until after the placenta is born 

Note whether you would like active management (Pitocin and cord traction) or expectant management of the third stage of labor. 

Note if you would like to see and/or keep your placenta. 

Under cesarean preferences, include any of the following: 

• I would like the surgery explained as it is happening 

• I would like a clear drape for the surgery until baby is born or 

• I would like the drape lowered to see baby as they are being born

• I would like to delay cord clamping for the standard 60 seconds 

• I would like to delay cord clamping for as long as possible 

• I would like the cord to be left long so my partner or I can trim it

• I would like to delay weights, measurements and medications until after the golden hour so baby can be with me as soon as possible

• I would like help initiating breastfeeding in the OR if baby is cueing to feed

• If I am unable to hold baby due to nausea or other factors, I would like my partner to do skin to skin with baby 

• If baby needs to go to the NICU, I would like my partner to go with the baby and have my doula ready to enter the OR to be with me

• I would like to minimize separation; I would like the baby to stay in the room with me until I am ready to go to the recovery area and not leave ahead of me. 

Under baby preferences, please write your plan for feeding your baby and which baby medicines you accept or decline (Vitamin K, eye ointment, Hep B vaccine) 

Under other notes, add anything you would like your care team to know that was not included here.