Here's one which I have changed the name on, it's from someone I know and is natural birth focused but you'll still get plenty of ideas. Hope it comes out okay I copied it from word!
Birth Preferences
Our full names: Sarah Smith & Joe Bloggs
We like to be called: Sarah and Joe
Our birth attendant’s name is Kelly Zantey
Other notes: We will be HypnoBirthing
We’re hoping for a natural childbirth without unnecessary intervention or the use of drugs. We have asked a birth attendant to be present at the birth to help us work towards this. We appreciate your support with our birth preferences.
This plan represents our preferences, however we recognise that in the event of unforseen difficulties it may need to be re-negotiated. In this eventuality please discuss all procedure options with us.
ACTIVE BIRTH
I would prefer the freedom to choose positions, use the shower or bath and walk around in labour as desired.
I would like intermittent external foetal monitoring unless continuous monitoring is medically necessary.
I’d prefer not to be offered drugs, I am aware of the options for pain relief and will ask for it if needed.
As long the baby and I are fine, I would prefer to be free of time limits, and not have my labour augmented.
To have an episiotomy only if medically necessary. Please allow time for the perineum to stretch naturally.
CAESAREAN
If a caesarean becomes necessary I wish my partner to be with me if possible or alternately my birth attendant.
Unless prevented by medical emergency, I would like to have immediate contact with our baby.
I would lilke the opportunity to try to breastfeed our baby in recovery.
BIRTH AND SOON AFTER
Ideally I’d like my partner to ‘catch’ our baby.
I would like my partner to cut the cord.
Presuming our baby is well I would prefer:
To hold our baby immediately after the birth. All newborn procedures (weighing and measuring) to wait until I have had time to be with and breastfeed our baby.
I am comfortable with having the routine Syntocinon injection to help deliver the placenta, however I prefer you to wait until the umbilical cord stops pulsating before it is cut and clamped.
I’d prefer our baby to have the vitamin K as an oral dose (as opposed to injection) if possible.


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