BIRTH PLAN
This is the birth plan for ________, due on ________.
A. Location and Support.
1. I would like to give birth at the following hospital: ________.
2. My midwife's name is ________.
3. I will be using a doula named ________ to support me during my labor.
B. Delivery Method.
4. I plan on having a Vaginal birth.
C. Labor.
5. For the first stage of labor, I have the following preferences:
-- I would like to labor standing up
-- the baby should be monitored via continuous monitoring
-- labor augmentation only if it is absolutely necessary
-- I would like to be given pitocin to progress my labor
-- I would like the medical team to rupture or strip the membranes if it will progress labor
-- I would like the the following method(s) of augmentation be used:
________
6. For pain management, I would like an epidural.
7. During labor, I would like to:
-- play my own music
-- have the room as quiet as possible
-- wear my own clothes
-- have as few vaginal exams as possible
-- stay hydrated with clear liquids and/or ice chips
D. Delivery.
8. I would like to deliver in a squatting position.
9. I would like to be coached on when to push.
10. I would like to see the baby crown.
11. I would like my support person(s) or another designated individual to take pictures of the birth.
12. I would like my support person to catch the baby.
13. I would like my support person to suction the baby.
14. I understand that a C-Section may become necessary. If that is the case, I would like a second opinion to be sure that there are no other options. I have the following preferences about a medically necessary c-section:
-- I would like to remain conscious during the procedure
-- I would like the support person of my choice to remain during the procedure
-- I would like the screen lowered so I can watch
-- I would like my hands free to touch the baby once it is born
-- I would like the procedure explained to me as it happens
15. I have the following preferences about the umbilical cord:
-- I would like my support person to cut the umbilical cord.
-- I would like to bank the cord blood.
16. I would like for the placenta to be saved for later use.
E. Baby Medical Procedures.
17. I would like my baby's initial medical exam to be given in my presence.
18. I would like my baby's initial medical exam to occur after I have had a chance to bond with the baby.
19. I would like my baby's medical exam to include the following procedures(s):
-- A heel stick procedure
-- A hearing screening test
-- A hepatitis B vaccine
20. I would like my baby to be circumcised as soon as possible after birth.
21. I would like my baby to be given anesthesia during the circumcision procedure.
22. I would like my baby's circumcisions to happen in my presence.
F. After Birth.
23. I would like to hold my baby as soon as possible after delivery.
24. I do plan to breastfeed and have the following preferences about breastfeeding:
-- I would like to breastfeed on a to be determined schedule
-- I would like to consult with a lactation specialist
25. I would like my baby in the room with me all the time, including both day and night.
26. I would like any visitors to come join me in my room immediately after delivery.
I have made a living will or designated a health care power of attorney that I would like my birth team to be made aware of and that paperwork will be attached to my birth plan.
SIGNED,
_______________________________
________, Birthing Parent
DATED: ___________________
BIRTH PLAN
This is the birth plan for ________, due on ________.
A. Location and Support.
1. I would like to give birth at the following hospital: ________.
2. My midwife's name is ________.
3. I will be using a doula named ________ to support me during my labor.
B. Delivery Method.
4. I plan on having a Vaginal birth.
C. Labor.
5. For the first stage of labor, I have the following preferences:
-- I would like to labor standing up
-- the baby should be monitored via continuous monitoring
-- labor augmentation only if it is absolutely necessary
-- I would like to be given pitocin to progress my labor
-- I would like the medical team to rupture or strip the membranes if it will progress labor
-- I would like the the following method(s) of augmentation be used:
________
6. For pain management, I would like an epidural.
7. During labor, I would like to:
-- play my own music
-- have the room as quiet as possible
-- wear my own clothes
-- have as few vaginal exams as possible
-- stay hydrated with clear liquids and/or ice chips
D. Delivery.
8. I would like to deliver in a squatting position.
9. I would like to be coached on when to push.
10. I would like to see the baby crown.
11. I would like my support person(s) or another designated individual to take pictures of the birth.
12. I would like my support person to catch the baby.
13. I would like my support person to suction the baby.
14. I understand that a C-Section may become necessary. If that is the case, I would like a second opinion to be sure that there are no other options. I have the following preferences about a medically necessary c-section:
-- I would like to remain conscious during the procedure
-- I would like the support person of my choice to remain during the procedure
-- I would like the screen lowered so I can watch
-- I would like my hands free to touch the baby once it is born
-- I would like the procedure explained to me as it happens
15. I have the following preferences about the umbilical cord:
-- I would like my support person to cut the umbilical cord.
-- I would like to bank the cord blood.
16. I would like for the placenta to be saved for later use.
E. Baby Medical Procedures.
17. I would like my baby's initial medical exam to be given in my presence.
18. I would like my baby's initial medical exam to occur after I have had a chance to bond with the baby.
19. I would like my baby's medical exam to include the following procedures(s):
-- A heel stick procedure
-- A hearing screening test
-- A hepatitis B vaccine
20. I would like my baby to be circumcised as soon as possible after birth.
21. I would like my baby to be given anesthesia during the circumcision procedure.
22. I would like my baby's circumcisions to happen in my presence.
F. After Birth.
23. I would like to hold my baby as soon as possible after delivery.
24. I do plan to breastfeed and have the following preferences about breastfeeding:
-- I would like to breastfeed on a to be determined schedule
-- I would like to consult with a lactation specialist
25. I would like my baby in the room with me all the time, including both day and night.
26. I would like any visitors to come join me in my room immediately after delivery.
I have made a living will or designated a health care power of attorney that I would like my birth team to be made aware of and that paperwork will be attached to my birth plan.
SIGNED,
_______________________________
________, Birthing Parent
DATED: ___________________
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