My Birth Plan
Full Name: Madison
Partner’s Name:
Due Date/ Induction Date: June 25th 2015
Doctor’s Name:
Hospital Name:
Please Note That I Have:
Have group B strep
Am Rh incompatible with baby
Have gestational diabetes
None of these
My Delivery is Planned as:
Vaginal
C-Section
I would like:
Partner:
Parents: Trudy (before and during), Scott (before)
Other: My daughter Chloe (before)
...Present before and/or during delivery.
During labor I would like:
Music played
The lights dimmed
The room as quiet as possible
As few interruptions as possible
As few vaginal exams as possible
No students or interns
To wear my own clothes
My labor/delivery filmed and or pictures taken (by:____________________)
My partner to be present at all times
To stay hydrated with clear liquids and ice chips
To eat and drink as approved by my doctor
I would like to spend the first stage of labor:
Standing
Lying down
Walking around
Sitting
All the above
I would like labor augmentation:
Performed only if baby is in distress (1st)
Performed by membrane stripping (1st)
Performed by pitocin
Performed by rupture on the membranes (3rd)
First attempted by natural methods (2nd)
For pain relief I would like to use:
Breathing techniques
Distraction
Massage
Meditation
Hypnosis
Standard epidural
Nothing
Only what I request at that time
Whatever is suggested at that time
During delivery I would like to:
Squat
Semi-recline
Lay on my side
Be on my hands and knees
Lean on my birthing partner
Use people for leg support
Use foot pedals for support
As the baby is delivered, I would like to:
Push spontaneously
Push as directed
Use a mirror to see the baby crown
Touch the head as it crowns
Let the epidural wear off while pushing
Have a full dose for epidural
Push without time limits, as long as baby and I are not at risk
Avoid forceps usage
Avoid vacuum extraction
Help catch the baby
Let my partner help catch the baby
Let my partner suction the baby
Use whatever methods my doctor deems necessary
I would like an episiotomy:
Rather than risk a tear
Performed only as last resort
Not performed, even if risking a tear
Performed if doctor deems necessary
Performed with local anesthesia
Followed by local anesthesia for repair
If C-section is necessary, I would like:
A second opinion
To stay conscious
My partner to stay with me at all times
To make sure all options are exhausted
The screen lowered so i can watch the baby come out
My hands free so I can touch the baby
The surgery explained as it happens
To breastfeed in the recovery room
My partner to hold the baby as soon as possible
Immediately after delivery, I would like:
My partner to cut the umbilical cord
To bank the cord blood
To donate the cord blood
To see the placenta before it is discarded
To deliver the placenta spontaneously and without assistance
I would like to hold the baby:
Immediately after delivery
After suctioning
After weighing
Before eye drops/ointment are given
After being wiped clean and swaddled
I would like to Breastfeed:
As soon as possible after delivery
Before eye drops/ointment are given
Later
Never
I would like my family members:
To join me and the baby immediately after delivery
To join me and the baby in the room later
Only to see the baby in the nursery
To have unlimited visiting after birth
Please don’t give the baby:
Vitamin K
Antibiotic eye treatment
Formula
A pacifier
I would like baby’s medical exams and procedures:
Given in my presence
Given only after we’ve bonded
Given in my partner’s presence
To include a hearing screening test
To include a hepatitis B vaccine
To include a heel stick for screening tests beyond the PKU
I would like the baby’s first bath given:
In my presence
In my partner’s presence
By me
By my partner
I would like to feed the baby:
Only with breastmilk
Only with formula
On demand
On schedule
With help from a lactation specialist
I would like the baby to stay in my room:
All the time
During the day
Only when I’m awake
Only for feeding
Only when I request
I would like my partner:
To sleep in my room
To have unlimited visiting
If we have a boy, a circumcision should:
Be performed
Not be performed
Be performed later
Be performed with anesthesia
be performed in the presence of me and/or my partner
As needed post-delivery, please give me:
Extra-strength acetaminophen
Stool softener
Laxative
After birth, I would like to stay in the hospital:
As long as possible
As briefly as possible
If the baby is not well, I would like:
To hold the baby whenever possible
To breastfeed or provide pumped breastmilk
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