This customizable template is designed for a vaginal, unmedicated hospital birth. However, it can be modified to suite any birth intention. It includes twenty two items for labor, delivery, and postpartum.

This template also includes the official statement from ACOG around the informed consent process. In particular, "a patient's right to make her own decisions about medical issues extends to the right to refuse recommended medical treatment. The freedom to accept or refuse recommended medical treatment has legal as well as ethical foundations." Ethical Decision Making in Obstetrics and Gynecology (2016)

Adjust this exemplar to your preferences and share with your birth team.