Templates / Visual birth plan: Printable form and one-page summary guide

Clinical guides

Visual birth plan: Printable form and one-page summary guide

Free PDF • 3 pages, print-ready • Clinician-reviewed

Monika Lazarevska Last updated October 29, 2026 Reviewed by Dr. Vanja Kitanova

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A visual birth plan is a short birth preferences document that your care team can scan in seconds. It uses tick-boxes, icons or brief labels instead of paragraphs. Labor rooms are busy and staff change shifts, so a plan that reads at a glance is the one that gets used.

This free template is a three-page printable checklist form. It has sections for personal details, delivery, feeding, pain relief, birth, newborn care and postpartum care. Some wording on the form is US-style, so adapt it to your own hospital or birth center. Fill it in at a prenatal visit, then condense your top choices onto one page for the delivery room.

Template details

Template type

Plan

Format

Printable PDF, 3 pages

Sections

8 sections

Fields to complete

4 fields

Best for

Clinical guides

Key takeaways

A visual birth plan lets your care team read your main preferences in seconds.

The free form runs to three pages of tick-boxes and short fill-in fields, ordered from labor to recovery.

Fill it in at a prenatal visit, then condense your top choices onto a one-page summary for the delivery room.

Adapt US-style wording, such as Labor Tub or Dermoplast, to the options your hospital or birth center offers.

Share copies with your midwife or obstetrician, your birth partner and your hospital bag before labor starts.

A visual birth plan puts your choices where staff can find them

A visual birth plan is a birth preferences document built for scanning. It uses tick-boxes, short labels and sometimes icons instead of long paragraphs. Each section covers one area of care, such as pain relief or newborn care, so a nurse or midwife can find one preference fast.

The format suits teams working under time pressure. Staff may change shifts during a long labor, and each new person needs your key wishes quickly. Clear marks carry the core message. A few words then add the detail that matters, such as which pain relief you would try first.

What the free form covers, page by page

The downloadable template is a three-page printable checklist. It has no icons. Instead, each section uses tick-boxes or short fill-in fields, and the sections follow the day in order.

Page 1 holds the planning details, from your due date to your feeding plan. Page 2 covers labor, birth and the first hours with your baby. Page 3 deals with recovery, NICU wishes and COVID-19 considerations. The map below shows where each of the 16 sections sits.

Some wording on the form is US-style. It names items such as a “Labor Tub” and Dermoplast spray, plus procedures like circumcision. Cross out or rename any option your hospital or birth center does not offer. Then check local guidance with your midwife or obstetrician, such as NICE intrapartum care guidance in the UK.

Visual or written: Which plan works better in labor

A written birth plan is a narrative document, while a visual plan is a scannable summary. Both record the same choices, but they serve the reader differently.

Many parents use both. The visual summary goes to the team, and a longer note explains a complex situation, such as a previous difficult birth. The visual version is the one most likely to be read in the moment.

How to fill in the form step by step

Start in the third trimester, once you have had a few prenatal appointments and know your options. Sit down with your birth partner, because many choices on page 2 involve them.

1. Download the template and print all three pages on standard paper. On US Letter, choose “fit to page” so no fields are cut off.
2. Complete the personal information block first, including your provider, due date and GBS status if you know it.
3. Tick the boxes that match your preferences and fill in the blanks, one section at a time.
4. Mark your first choice clearly, then note any alternatives you would accept.
5. Add a one-page summary on top if you want a quicker read.
6. Review it with your midwife or obstetrician at a later prenatal visit, and update it as plans change.

Leave a section blank rather than guess. A blank tells staff to ask you, while a rushed tick can send them the wrong signal.

Boxes on the form that need extra care

A few boxes need more than a tick. Check these before you print your final copy.

Some boxes pair unrelated choices. The newborn care section reads “Eye Ointment, Vitamin K Shot”, “Blood Test, Hepatitis B Vaccine” and “Hearing Screening, Circumcision”. One tick can’t show which item you mean. Write “yes” or “no” beside each item instead. Do the same for any box that lists more than one option, such as the comfort measures on page 3.

Most of these newborn procedures are routine recommendations. The American Academy of Pediatrics recommends a vitamin K shot for every newborn. Babies who miss it face a higher risk of vitamin K deficiency bleeding, a rare but serious disorder.

Newborn blood screening and hearing tests are standard checks, and many US states require eye ointment by law. Talk any of them through with your provider before you decide to decline one.

The “Immediately Following Birth” box offers “Breastfeed Within 1-2 Hours”. The World Health Organization recommends starting within the first hour instead. If you plan to breastfeed, ask your team to support skin-to-skin contact and a first feed in that hour.

Page 3 still carries a COVID-19 section. You can skip it, or use it to note any infection-control rules your hospital has now, such as visitor limits.

Condense the three pages into a one-page visual summary

Three pages are thorough, but nobody reads them between contractions. A one-page summary on top fixes that. Keep the full form in your notes, and hand staff the summary.

Before you print the summary, run through this checklist:

• Pick six to eight preferences that matter most, drawn from all four stages of the day.
• Give each one a simple icon or symbol and a label of five words or fewer.
• Put non-negotiables first, such as allergies or who may be in the room. The form has no allergy field, so copy them from the Pre-existing Conditions box.
• Add one line for plan B, for example your wishes if you need a cesarean.
• Leave white space, and use a font you can read at arm’s length.

Free design tools and printed stickers both work for the icons. Just make sure each symbol means one choice, and the label says which one. The example below shows how a finished summary can look.

Common mistakes that make a birth plan hard to use

Most problems show up on the day, when staff try to act on a plan that contradicts itself. These are the ones to check for:

• Ticking conflicting options. Delayed cord clamping appears in two sections, so make sure both answers match.
• Leaving GBS status blank. In the US, group B strep status affects whether you need antibiotics in labor, so ask for your result first. The NHS does not routinely test for GBS in pregnancy, so UK readers can write “not tested”.
• Planning for one kind of birth only. The delivery section lists induction, planned C-section and TOLAC/VBAC. A VBAC birth plan covers the extra decisions after a previous cesarean.
• Ranking pain relief without context. Epidural, nitrous oxide and water are all valid choices. A pain scale for giving birth gives you and staff shared words for how labor feels.
• Keeping a single copy. A plan that stays in your bag never reaches the person caring for you.

Share the plan before labor starts

Sharing works best when the plan reaches people early. Bring a copy to a prenatal appointment, and ask your midwife or obstetrician to add it to your notes.

• Print two copies of the full form, one for your notes and one for your bag.
• Pack the one-page summary on top, next to the items on your hospital bag checklist.
• Send a digital copy to your birth partner and any doula.
• Ask where the plan will be filed in your maternity record.
• Pin the summary to the birth room wall if your setting allows it.

If a fertility clinic cared for you early in pregnancy, ask it to send its notes to your maternity team. Many fertility practices keep those notes in fertility clinic software, so a digital copy is quick to send.

Your choices on page 3 also carry into recovery. They give you a head start on a postpartum care plan for the weeks after birth.

How Pabau helps practices collect birth plans before the due date

Many OB-GYN and midwifery practices still hand out paper birth plans. Parents fill them in at home, forget them on the day, or bring a different version to each visit. Staff then re-key the choices into the chart by hand.

Pabau, the practice management platform we build, turns a form like this into a digital form that patients complete before their appointment. Their answers flow into the patient record automatically. That way, every clinician at the next prenatal visit sees the latest version.

Practices use Pabau as OB-GYN EMR software, with scheduling, reminders and invoicing in the same system. Staff can see which patients have completed their forms before the visit, so nobody chases paper on the day.

Collect birth plans before the due date

Pabau’s digital forms let patients complete their birth preferences before a prenatal visit. Answers save to the patient record, so the whole care team reads the same plan.

Book a demo

Conclusion

A birth plan helps only if someone reads it at the right moment. The three-page form does the thinking, and the one-page summary gets it read. Treat both as a starting point for talks with your care team, because labor can change the plan.

Finish the form early in the third trimester, and review it at your next prenatal visit. Whenever a choice changes, update the summary and replace every printed copy.

Running an OB-GYN or midwifery practice? Book a demo to see how Pabau collects birth plans digitally and keeps them in each patient’s record.

Continue your research

Want a different birth plan layout? Mama Natural birth plan template offers a written alternative for parents planning an unmedicated birth.

Supporting a patient through labor? Labor and delivery nursing care plan sets out nursing goals and interventions from admission to birth.

Still preparing for the baby’s arrival? Newborn essentials list covers the supplies to have ready before you come home.

Planning recovery after birth? Postpartum checklist tracks the key recovery milestones of the fourth trimester.

Thinking ahead to feeding changes? Breastfeeding weaning plan gives a gradual schedule for moving off breastfeeding.

Frequently asked questions about birth plans