I was so skeptical having a hospital birth after delivering my first daughter at home via water birth with a midwife. I know being in a hospital means more medical intervention, which I wanted the least amount of interventions.
Feel free to copy this and use for yourself or only take bits and pieces if you like.
Birth Plan
My Name and My Husbands Name
Patient
of:
Pediatrician:
Estimated Due
Date: 8/31/2011
Labor:
I would like to be free to walk around, use my birthing ball
during labor and/or use the birthing tub or shower.
I wish to be able to move around and change positions during
labor.
I will be bringing my own music to play during labor.
I would like the environment to be kept as quiet as
possible.
I would like the light to be kept low in the room during my
labor.
I do not want vaginal exams during labor unless it is
absolutely necessary.
Monitoring:
I do not wish to have
continual fetal monitoring unless it is required by the condition of my
baby.
Labor Augmentation/Induction:
I would prefer to change
positions and to try other natural methods (walking, nipple stimulation,
etc.) to help labor before pitocin is
administered.
I do not wish to have the
amniotic membrane ruptured artificially.
Anesthesia/Pain Medication:
I do not want to be offered pain medicine, I will ask for
them if I need them.
Before considering an epidural, and if the
situation warrants, I would like to try an injection of a narcotic pain relief.
Cesarean:
Unless absolutely necessary, I would like to avoid a
cesarean.
If a cesarean delivery is indicated, I would like
to be fully informed and to participate in the decision making process.
My husband would like to be there at all times if my baby
requires a cesarean delivery.
If my baby is not in distress, my baby should be
given to my husband immediately after the birth and stay with him until I am
out of surgery. My husband would like to
use the warmth of his body and not heating lamps to keep the baby warm.
Episiotomy:
I would prefer not to have an episiotomy unless absolutely required
for the baby’s safety.
If possible, I would like to use perineal massage to avoid
an episiotomy.
Delivery:
I would like to choose the position in which I give
birth including squatting or a hands and knees position. If the birthing tub is available to use I
would like to have the option to deliver in the tub.
I would appreciate having the room lights turned low for
actual delivery.
I would like to have the baby placed on my stomach/chest
immediately after delivery.
During delivery I want as few of the medical staff in the
room as possible.
During the delivery, my 3 year old daughter and her
caretaker may or may not be present.
Immediately After Delivery:
I would like to have my husband cut the cord only after the
cord stops pulsating.
I would like to hold my baby while I deliver the placenta
and any tissues are repaired.
My baby will be evaluated in my presence.
I plan to nurse immediately following the birth to
aid the delivery of the placenta.
I plan to practice Kangaroo Mother Care and would
appreciate if the evaluation of my baby be done with my baby on my abdomen,
with both of us covered by a warm blanket, unless it is absolutely unavoidable.
If my baby must be taken from me to receive medical
treatment and conditions are such that my husband or I cannot be with him/her,
we would like her brought back as soon as possible.
I would prefer to hold my baby on my chest between
my breasts instead of having him placed under heat lamps so he may receive the
warmth of my body and the reassuring sound of my heartbeat(Kangaroo Mother
Care).
After the birth I would prefer to be given a few
moments of privacy to urinate on my own, before being catheterized.
No eye ointment will be administered to my baby as
discussed with my pediatrician (Dr. Capone). I do not have any STD’s and it is
unnecessary.
Do not give my baby any vaccinations.
I would like to nurse/hold my baby while he/she
receives the vitamin k shot and PKU test.
Do not remove my child from my room without my
consent.
Postpartum:
Unless required for health reason, I do not wish to be
separated from my baby.
Please perform the bath in my room and allow my husband to
aid in bathing our son.
As I discussed with my pediatrician, he will
examine my child in my room with me present.
Our son will not be circumcised.
Depending on the time of the birth, we would like avoid an
overnight stay if possible assuming that there are no complications.
Breastfeeding:
I plan to breastfeed my baby and would like to begin nursing
immediately after birth.
My baby may not have formula/fluids (including
glucose water).
