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A sample birth plan

Here is a sample birth plan Remember, this is just an EXAMPLE, and is not necessarily the best one for you, but it gives you an idea of the kinds of questions a doula may help you to answer in a birth plan.




Whether you’re planning a natural, non-medicated birth or an assisted delivery, (one that includes an epidural), this birth plan may prove to be helpful.

Don’t be overwhelmed with all the choices we have prepared for you. Simply click on the options that are right for you and let us help make your birth easy and effortless. Prepare at least 5 copies and present them to your doctor, midwife, nurse, and any attending family or friends before you start your labor.

First Name____________________________________________
(required)
Last Name____________________________________________
(required)
Partner's Name________________________________________

Attendants Name- If Doula or other profession will be present in addition to Partner.___________________

Due Date
(required) Choose Month January February March April May June July August September October November December

Choose Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Choose Year 2006 2007

Address
City
State
Zip
Email
My Doctor

__As long as the baby and I are healthy, I would like to go at least 10 to 14 days over my due date before inducing labor. I want all aspects of induction clearly explained and I want to given all of my options.
__As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy.
__I would like to discuss laboring at home as long as possible.
__I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan.
__If Fetal Non Stress observations becomes necessary after my due date, I am flexible and support this procedure.
__I would like to discuss the option of induction before I reach my due date.
__If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced.

Vaginal exams examinations
__Please obtain my permission before stripping my membranes during a vaginal exam.
__I prefer to have no vaginal exams until I go into labor.
__I prefer to have only 1 vaginal exam on or around my due date. __I want no vaginal examinations during the labor and prelaboring period.
__During a vaginal exam, I prefer at no time to have my membranes broken unless there is an emergency situation.
__I prefer minimal internal vaginal exams or at my request only.
__I would like no internal vaginal exams, within reason, during my labor until I have an urge to push.
__I prefer to have minimal internal exams

Hospital Admittance
__I would like the option of staying in the hospital regardless of my dilation and the discussion of induction.
__If I am less than five centimeters dilated, I would like the option of going home.
__If I am less than five centimeters dilated and my water has broken, I would like the option of returning home.

If induction becomes necessary, I would like to try natural induction techniques first (with the guidance of my practitioner)
Natural induction techniques I would like to try (check all that apply) :
_Breast stimulation
_Walking
_Herbs
_Enema
_Castor oil
_Chiropractic
_Acupuncture
_Sexual intercourse
_Massage
_Reflexology
_Yoga

If Medical induction becomes necessary, I prefer to try (check all that apply) :
_Stripping membranes
_Prostaglandin gels
_Pitocin

Rupturing membranes
If my water breaks before I go into labor, I would like to:
wait 6 hours before being induced
wait 12 hours before being induced
wait 24 hours before being induced
wait 48 hours before being induced
have no time limits and talk about alternative treatment such as antibiotics

Upon arrival at the hospital, I prefer to have my partner with me at all times.
Please, no residents or students attending my birth.
I request the following people to be present during my labor and/or 2nd stage labor:
Partner Name:
Relative(s) Name(s):
Friend(s) Name(s):
Doula Name:
Sibling(s) Name(s):

Please do not allow in my room at any time.
I prefer to give birth in a:
Birthing room
Room with a shower and/or bath
Delivery room
At home
If birth equipment is available, I would like to use (check all that apply) :
Birthing bed
Birthing ball
Bean bag chair
Birthing tub/pool/shower
Birthing stool
Squatting bar
Miscellaneous environment items (check all that apply):
I would like to have dimmed lights.
I would like for people entering the room to speak softly.
I would like to play music.
I would like no one to speak during the actual delivery.
I would like to wear hospital clothing.
I would like to wear my own clothes during labor and delivery.
I would like to be reminded to remove my clothing during the actual delivery.
I would like to have a TV available.
I would like to have a VCR available.
I would like to wear headsets during my labor and delivery.
I would like to have my birth photographed.
I would like to have my birth filmed/videotaped.
I would like to wear my glasses or contact lenses unless removal becomes medically necessary.
I would like to have no restrictions on food or fluids during my labor.
I prefer to have an IV.
I prefer to have a heparin or saline lock.
I prefer to have no IV.

Please only offer pain medications if I ask for them.
Please suggest pain management options for me if you see that I am too uncomfortable to handle the pain.
Please discuss pain management options for me as soon as possible.
After medical guidance for pain relief, I would appreciate some private time with my partner to discuss which pain management technique or medication I would like to use.
I am prepared to try to handle pain with these natural and alternative methods (check all that apply):
Breathing techniques
Distraction techniques
Hypnotherapy
Acupressure
Acupuncture
Massage
Visual imaging work
Color therapy
Deep (or guided) relaxation
Water/bath/shower
If I choose to use drugs, my preference is:
Walking epidural
Classic epidural
Sedative
Tranquilizer
Narcotics
Other Considerations
Ultimately, I want to be able to walk around and move as I wish while in labor.
Ultimately, I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor.
Please keep my door always closed during labor.

I prefer the baby to be monitored:
Externally, continuously
Externally, intermittently
Intermittently using a doppler
Intermittently using a fetoscope
Internally
I have prepared for this birth with:
Lamaze techniques
Bradley techniques
Hypbirth (childbirth hypnosis)
Other:

I am seeking my practitioners assistance with this technique.

As long as the baby and I are healthy, I prefer to have no time limits on pushing.
If pushing for more than several hours, I am open to medical intervention in 2nd stage labor.
I would like to be encouraged to try the following different positions for labor (check all that apply) :
Squatting
Classic semi-recline
Hands and knees
On the toilet
Standing upright
Side Lying
Whatever feels right at the time

I will ask for an enema if I feel that I need one.
I would like to have an enema upon being admitted.

I prefer to have an episiotomy
I prefer to have no episiotomy and risk tearing (unless I'm having a medical emergency)
If I need an episiotomy, I prefer a pressure episiotomy.
To help prevent tearing, please apply:
Hot compresses
Oil
Perineal massage
Encourage me to breathe properly for slower crowning.
Other labor considerations
If possible, please allow the shoulders and body of my baby to be born spontaneously, on their own.
Please use a local anesthetic for repairs.
No stirrups please unless I'm having a medical emergency

If intervention is needed for an assisted vaginal birth, I prefer:
Forceps
Vacuum extraction
Misc. (check all that apply):
I would like to view the birth using a mirror.
I would like to touch my baby's head as it crowns.
I would like to catch my baby and pull it onto my abdomen as it is born.
I would like my partner to catch my baby.
I would like the doctor to catch my baby.
For spiritual or religious reasons, I would like the room to be totally silent as the baby is born.
I would like for our baby to hear our voices first.
I prefer to have the lights dimmed for delivery or, if it is daylight, to access only natural light.


Pushing
It's important to me to push instinctively. I do not want to be told how or when to push.
Please tell me when to push
After Baby is Born
As long as my baby is healthy, I would like my baby placed immediately on my abdomen following the birth.
Please put my baby skin-to-skin on my abdomen with a warm blanket over it.
Please do not separate me and my baby until after my baby has successfully breastfed on both breasts.
Please delay all essential routine procedures on my baby until after the bonding and breastfeeding period (i.e., bathing).

If a C-Section is not an emergency, please give us time alone to think about it before asking for our written consent.
My partner(s) is(are) to be present at all times during the c-section.
Ideally, I would like to remain conscious during the procedure.
I would like the baby to be shown to me immediately after it's born.
I would like to have contact with the baby as soon as it is possible in the delivery room.
I prefer to have a hand free to touch the baby.
We would like to photograph or film the operation as the baby comes out.
We would like to film or photograph only the baby after delivery.
If possible, please discuss anesthesia options with me (including morphine options).
I prefer a low transverse incision on my abdomen and uterus.
Please respect my wishes to be quiet during the operation (e.g., avoiding "small talk" with other practitioners in the room).
Recovery (check all that apply)
If my baby is healthy, I would like to hold my baby and nurse it immediately in recovery.
I would like to sign any waivers necessary to permit me to be with my baby in recovery.
As long as my baby is healthy, I would like my partner to be the baby's constant source of attention until I am free to bond with it (i.e., holding, skin-to-skin contact, etc.).
I would like my baby to be sent to the nursery while I am in recovery.
Please pay special attention to our nursing needs in recovery. I may need some "extra help" nursing after the operation.
I would like to have my catheter and IV removed ASAP after my recovery period.
Please discuss with me what I can expect to feel immediately following the procedure.
Please discuss my post-operative pain medication options with me before or immediately following the procedure.

Please wait for the umbilical cord to stop pulsating before it is clamped.
Please allow my partner to cut the umbilical cord.
Placenta (check all that apply):
I would prefer for the placenta to be born spontaneously without the use of pitocin, and/or manual extraction.
I would like to have routine pitocin given to me after the placenta is born.
I would like to delay routine pitocin after the placenta is born unless there are any signs of hemorrhaging.
I would like the option of taking home the placenta.
I would like to bank my baby's cord blood and have made arrangements for this procedure prior to the birth.

If the baby has any problems, I would like my partner to be present with the baby at all times, if possible.
I would like to have routine newborn procedures delayed until bonding and breastfeeding have occurred.
I would like all newborn routine procedures to be performed in my presence.
I would like all newborn routine procedures to be performed right away.


Administration of Eyedrops
I would like my baby to be administered eyedrops immediately after birth.
I would like to delay the administration of eyedrops up to two hours after birth.
I would like no administration of eyedrops to my baby and am willing to sign a formal waiver if need be.
Vitamin K
I would like my baby to receive a routine injection of vitamin K immediately after birth.
I would like to delay the administration of vitamin K up to 2 hours after birth unless medically necessary.
I would like only the orally administered vitamin K to be given to my baby.
Please do not administer vitamin K to my baby.


Immunizations
I prefer any immunizations be postponed to a later time
Immunuze the baby according to normal procedures.
Bathing Baby
Please bathe my baby after we have had time to bond with it.
Please do not bathe my baby.
We would like to give our baby its first bath. Please help direct us in this process at the hospital.


Circumcision:
Please do not circumcise him.
I would like him circumcised
Other circumcision options:
Please use a local anesthetic
Please delay procedure as long as possible


PKU
Routine PKU Testing right away
We would like routine PKU testing to be done before we leave the hospital.
We decline routine PKU testing at the hospital and have made other arrangements for this procedure at a later date this week.
We would like to wait, and delay the PKU testing until we are ready to leave the hospital


Feedings
My baby is to be exclusively breastfed.
My baby is to be formula-fed exclusively.
I would like to combine breastfeeding and formula feeding.
Please offer guidance on the issue of formula versus breastfeeding.
I would like to see a lactation consultant as soon as possible for further recommendations and guidance.
Do not offer my baby the following without my consent (check all that apply):
Formula
Pacifiers
Any artificial nipples
Sugar water


If my baby's health is in jeopardy, I would like (check all that apply):
To be transported with my baby if possible.
My partner to go with the baby.
To breastfeed or express my milk for my baby.
To have no time restrictions with my baby.
To have as much bodily contact with my baby as possible.
To be offered a room at the hospital for the duration of my baby's stay (within reason).


Other:
I would like my in-hospital routine to be:
Full rooming in, no separation, no exceptions, unless my baby is sick.
Delayed rooming in until I have had time to rest.
Partial rooming in. I prefer to have the baby sent to the nursery at night so that I can rest.
Nursery care: I would like the nursery to fully care for my baby and bring it to me for feedings.

I prefer to have my hospital stay:
As short as it can be.
As long as it can be.
Other hospital preferences:
I prefer a private room.
I prefer to have my partner stay with me for the duration of my hospital stay.
I would like my other children (regardless of age) to be allowed to visit with me for as long as they wish or as long as hospital policy permits.
I would like my guests to be permitted to stay as long as they wish.
I want privacy during my stay and for my guests to limit the time they are visiting me.