About this template
A birth plan form is an essential communication tool created by an expecting mother to outline her personal wishes, needs, and medical preferences for labor, delivery, and postpartum care. It ensures that physicians, midwives, doulas, and hospital staff clearly understand her choices regarding pain management, support personnel, newborn procedures, and feeding preferences.
Using this digital birth plan template, healthcare providers and expecting parents can easily outline and review preferences before the big day. Doc2Form makes it simple to customize the template, add practice-specific details, and share the form with patients so they can complete it from home or during a prenatal visit. Streamline your obstetrics practice and ensure every patient's voice is heard during childbirth.
Key features
- Capture labor and delivery preferences clearly before due dates.
- Organize medical team details, support people, and contact information.
- Specify pain management, intervention, and newborn care choices.
- Easily shareable with patients for completion at home or during prenatal visits.
Use cases
Collecting labor and delivery preferences in obstetrics and midwifery…
Collecting labor and delivery preferences in obstetrics and midwifery clinics.
Guiding prenatal consultations between expectant mothers and their do…
Guiding prenatal consultations between expectant mothers and their doulas or OB-GYNs.
Preparing hospital maternity wards with patient-specific care plans i…
Preparing hospital maternity wards with patient-specific care plans in advance.
What this form collects
- Your Full Name (Short answer)Enter your first and last name.
- Expected Due Date (Date)Select your estimated due date.
- Phone Number (Short answer)Enter the best phone number to reach you.
- Email Address (Short answer)Where can we send a copy of your completed plan?
- Partner Name (Short answer)Enter the name of your partner or primary support person.
- Baby's Name or Nickname (Short answer)If you have chosen a name or nickname, let us know.
- Care Providers (Paragraph)List your primary OB-GYN, Midwife, and Pediatrician.
- Current Medication Status (Paragraph)List any prescription medications you are currently taking.
- Known Allergies (Paragraph)List any drug or food allergies, or type 'None'.
- Preferred Method of Delivery (Multiple choice)Select your primary preference.
- Delivery Room Environment (Checkboxes)Select your preferences for lighting, music, and atmosphere during labor.
- Labor Discomfort Management (Multiple choice)Indicate your pain management preferences.
- Umbilical Cord & Placenta Plan (Paragraph)Note your preferences regarding cord clamping and placenta handling.
- Feeding Preference (Multiple choice)How do you plan to feed your newborn initially?
- Additional Notes & Special Requests (Paragraph)Share any other specific wishes or concerns for your birth experience.
FAQ
What is the purpose of a birth plan?
A birth plan helps expecting mothers communicate their preferences and expectations for labor, delivery, and newborn care to their medical team, ensuring everyone is aligned.
Can I customize the questions in this template?
Yes! Once you generate your Google Form via Doc2Form, you have full control in Google Forms to add, remove, or edit any questions to fit your specific medical practice guidelines.
Who should fill out this form?
Expecting mothers typically complete this form during their third trimester in consultation with their OB-GYN, midwife, or doula.
How do patients access and submit the form?
You can share the Google Form link via email or text, embed it on your practice's website, or have patients fill it out on a tablet during an in-office appointment.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.