About Birth Plans & Birth Exemptions


For those who are planning a hospital birth but want to evade invasive routine post-natal procedures such as a Hep B shot, vitamin K injection, newborn screening, or the application of silver nitrate in the newborn’s eyes, a very specific birthing plan must be submitted to the hospital in advance of the birth. Hospital staff must be informed, in advance, of your needs, wants and desires where your baby and birthing experience are concerned. The same applies to midwives.


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– Create the birth plan. Or modify one of our ours to fit your state laws and any other personal circumstances. (click HERE for further information)

– Sign the birth plan in front of a Notary.

– Submit the birth plan to your hospital or midwife. Keep a couple extra copies in case plans

– Make sure affected parties (doctors, nurses, etc) understand your requirements and wishes.

– Plan on having one or two trusted persons stay with the mother and child to watch the child
at all times while in the hospital, to ensure that the baby isn’t given any unwanted
injections or other procedures. The support person stays with the baby if the baby is taken

– The birth plan arrangements and letter should be turned in before the delivery date.


To my birth attendants:

As a mother, I understand and accept that I am ultimately responsible for my own health and the health of my baby. I have made every effort to gain the knowledge and information that I need to make informed decisions. After a careful consideration of this knowledge as well as my own values and priorities, I have established some guidelines to help you care for me in a way which I feel is safest for me and my baby and also honors my needs and beliefs about birth.

I have complete faith in my body’s ability to give birth normally. I believe my body was designed to give birth and that it can do so with very little assistance. I wish to labor in the way I find most helpful, even if it differs from routine procedures. With help from my labor support person, I expect that I will require very little of your time and attention.

I have chosen a labor support person to be my birth advocate, and I authorize this person to see that my preferences as stated in this birth plan are carried out as closely as possible. This person will also provide physical and emotional support throughout the whole process of labor and delivery.

If at any time a physician feels that medical conditions warrant an intervention into the birth process, I am willing to discuss the proposed intervention as well as possible alternatives.
After discussing the situation, I will expect my final decision to be respected and honored, even if it differs from the opinions of others.

The following guidelines outline the kind of birth experience I desire for myself and my baby. No deviations should be made from this plan without my consent:

1. It is my desire to receive no assistance of any kind with my birth unless I specifically ask for that assistance. I am at the hospital only so that emergency help is available if necessary. I will require no routine care of any kind.

2. I will not be separated from my support persons for any reason unless I request it.

3. Absolutely no procedure will be performed on my baby without my authorization and I will be present for any procedure that is performed.

4. The umbilical cord will not be touched, clamped or cut until the placenta has been delivered.

5. Vitamin K shot will not be given under any circumstances.

6. No Vaccine will be given under any circumstance.

7. Since I have been tested for Gonorrhea, and my husband and I are in a monogamous relationship, no eye drops or ointment are to be put in my baby’s eyes.

8. If the baby is a boy, there will be no circumcision.

9. No PKU test will be administered in the hospital because the baby must nurse for at least two days before this is done. It will be my responsibility to see that the test is performed by a pediatrician at a later time.

10. No drugs of any kind will be administered during the labor and delivery process. I request that no offers for anesthesia be made to me by any doctor, nurse, or other hospital staff person. In the event that a cesarean section becomes necessary, I will decide at that time what kind of anesthesia will be used.

11. Pelvic exams will be performed only at my request.

12. I will have no perineal shave-prep.

13. No episiotomy will be performed on me under any circumstances. Perineal massage with oil, hot compresses, and perineal support will be used instead to prepare the perineal tissues to stretch. In the event that tearing of these tissues seems likely, I would prefer to allow the tissues to tear rather than be cut.

14. In order to allow the perineal tissues time to fan out so that no tearing takes place, and in order to reduce the risk of damage to the muscles of the pelvic floor, I will allow the baby to descend through the birth canal slowly and without sustained pushing efforts from me. I will only use exhale pushing, and only when I feel the urge to do so. As long as fetal heart tones are good, delivery is not to be rushed, but allowed to occur slowly and naturally.

15. The delivery will take place in a quiet, respectful atmosphere with dimmed lights, soft music, and quiet, calm speaking if speaking is necessary.

16. My amniotic membranes will be allowed to rupture spontaneously

17. Because of my belief that ultrasound is an unproven and possible unsafe technology, no electronic monitors or dopplers will be used. Monitoring of fetal heart tones will be done through fetoscope only.

18. I will be upright and active throughout my labor, walking as much or as little as I feel necessary, and assuming whatever position is most comfortable for me and helps assist the progress of labor.

19. It is my choice to give birth in the squatting position because of the obvious advantages it offers. If squat bars are not available, I will have two labor support persons with me to physically support me in this position while I give birth. I will require very little help from doctors or nurses to give birth because the squatting position encourages proper rotation, as well as quick and painless expulsion of the baby.

20. During labor and delivery I will be using vocalization as one of my tools for coping with labor. I find that it helps me to cope with the intensity of contractions while remaining totally relaxed. Hospital staff need to be aware that these vocalizations are constructive and that I am not making them because I am in pain, in distress, or need assistance.

21. As soon as the infant is delivered it is to be placed on my chest and observed for APGAR there. The infant will be allowed to nurse as desired so as to hasten the detachment and delivery of the placenta.

22. If the body temperature of the baby is of concern, the baby will be placed skin-to-skin with me and a warmed blanket will be spread over us both. At no time will the baby be separated from me and placed in a warmer.

23. All newborn care will be done in the same room with me and preferably with the baby in my arms. At no time will my baby be separated from me.

24. When one gives birth in the squatting position, suctioning of the baby is rarely necessary due to the natural drainage of fluids. If suction does prove to be necessary, deep suctioning of the infant will be done only if suction with a bulb syringe proves to be inadequate.

25. I request that a warm Leboyer bath be provided within one hour after birth to allow the baby to make a smooth and comfortable transition into the world. No soaps or disinfecting agents will be used to wash the baby, and vernix on his skin will be massaged into the skin rather than removed through washing.

26. My baby will not be given any substance by mouth other than my breast milk or colostrum. At no time will sterile water, glucose water, or formula of any kind be given. The baby will be allowed to nurse on demand, and no rubber nipples or pacifiers will be given. If the baby’s blood sugar level is of concern, more frequent nursing will be encouraged, since maternal colostrum provides a healthier and more stable blood sugar level than processed glucose.

27. I will eat light, non-constipating foods during early labor and clear liquids during active labor, if desired.




Posted by Erwin Alber – adapted from sample plan HERE



Commonly Asked Questions About Childbirth Answered

Writing Your Birth Plan: Tips from an L&D Nurse, PART 1

Top Ten DOs for Writing Your Birth Plan: Tips from an L&D Nurse, PART 2

How (and Why) to Create a Birth Plan

4 Simple Tips for Making a Birth Plan (That Gets Read)

Creating Your Birth Plan

Writing a Birth Plan

Birth Plans

Sample Natural Birth Plan (Birth Wishes)

10 FREE Printable Pregnancy Birth Plans & Hospital Bag Checklists for 2013

Birth Plan – Baby Center & HERE

Free Birth Plan

– Be Prepared for Your Delivery Before Labor Begins

Tool: Birth Plan

Interactive Birth Plan

Birth Plan Generator


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