Back to Birth Info Page Below is a birth plan suggestion. This gives you all the variables that are usually involved in a birth. Cut and paste this into your word processor, or print this out and edit according to your wishes. If you have any other considerations make sure that you note them. I am available to answer any questions you may have about this plan. It can greatly assist your labor and delivery. Birth Plan Your full name: Name of your caregiver: Name of Hospital/Birth Center: Due date: Coach/main support (i.e. my husband, my doula, my mother, my partner): How do you want the plan to refer to your baby? (our baby, my daughter, or the babies) Please Note I have tested positive for Group B Strep. My bloodtype is Rh- (Rhesus Negative). I have gestational diabetes. I am diabetic. I am hard of hearing. My vision is impaired. I would like to wear contact lenses or glasses at all times when conscious. Please perform no routine prepatory tasks (shaving, enema, etc.), unless requested. I expect that doctors and hospital staff will discuss all procedures with me before they are performed. I would like to be free to walk, change positions and use the bathroom as needed or desired. I prefer to wear my own clothes, rather than a hospital gown. I prefer to eat and drink throughout labor, as desired. I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips). So I can stay as mobile as possible, I would prefer to have a heparin lock adminstered instead of an IV. Please do not administer an IV or heparin lock unless there is a clear medical indication that such is necessary. I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions. I would like to play my own music. Please limit the number of vaginal exams. I wish to labor freely in the birthing tub or shower. As long as the baby is doing well, I prefer that fetal heart tones be monitored intermittently with an external monitor or doppler, even if the membranes have ruptured. If fetal distress is suspected and time permits, I would like confirmation of this with a fetal scalp blood sample before proceeding with other interventions. Please allow me to vocalize as desired during labor and birth without comment or criticism. I do not mind observation by students, interns or staff. Please do not permit observers such as interns, students or unnecessary staff into the room without my permission. To preserve my privacy and dignity, I would prefer that everyone knock before entering. Labor Augmentation/Induction I would like to avoid induction unless it is medically necessary. As long as the baby and I are healthy, I do not want to discuss induction prior to 42 weeks. If my pregnancy progresses past 40 weeks, I would prefer to base the decision to induce on the results of the baby's biophysical profiles, not on my own personal discomfort or impatience. I would like to try alternative means of labor augmentation, like walking or nipple stimulation, before pitocin or artificial rupture of membranes is attempted. If induction is necessary, I would like to attempt it with prostaglandin gel or cytotec, before pitocin is administered. If induction is attempted, but fails, I would like to come back at another time rather than pursue further intervention (assuming my amniotic sack is intact and that waiting presents no danger to the baby or myself). Please do not rupture my membranes artificially unless medically indicated. Anesthesia/Pain Medication Please do not offer anesthesia/analgesia unless I ask for it. If I ask for pain relief, please feel free to offer nonmedical choices for coping and/or remind me how close I am to the birth. I would like to avoid all narcotics, if possible. I prefer an epidural to narcotic pain medication. If pain relief is considered, I would like to try a narcotic before an epidural. I would like to try having narcotics-only administered in the epidural line before progressing to full anesthesia. I would like to have a light dose (walking) epidural. I would like the epidural to wear off slightly as I approach full dilation and the pushing stage. Birth Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase. I prefer to push or not push according to my instincts. I do not want to use stirrups while pushing. I would like the freedom to push and deliver in any position I like. I would appreciate help from (coach) and staff supporting my legs as I push. I would like to deliver in a birthing pool. I would like to have a mirror available and adjusted so I can see the baby's head crowning. I would like the opportunity to touch my baby's head as it crowns. I would like a soothing environment during the actual birth, with dim lights and quiet voices. I would like to help catch the baby. I would like (coach) to help catch the baby. I would like (other) to help catch the baby. I would like to have the birth recorded with photographs, video tape and/or tape recording. Perineal Care I prefer not to have an episiotomy unless it is medically indicated. To avoid episiotomy or tearing, (coach) or my labor assistant will perform perineal massage with oil and apply hot compresses. To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop. I would rather tear than have an episiotomy. I would rather have an episiotomy than risk a tear. Please administer local anesthesia when repairing any episiotomy or tear(s). Please suture tears only if necessary. After birth Please place the baby on my stomach/chest immediately after delivery. I would like to breastfeed the baby immediately. (coach) would like the option to cut the cord. (other) would like the option to cut the cord. I would like the option to cut the cord. Please allow the umbilical cord to stop pulsating before it is cut. I have made arrangements for donation of the umbilical cord blood. I have made arrangements to bank the umbilical cord blood. I prefer to wait for spontaneous delivery of the placenta and do not want a routine injection of pitocin. Please show me the placenta after it is delivered. I wish to take home the placenta Please remove my IV/Heparin lock/catheter as soon as possible after the birth. Cesarean Section Birth I feel very strongly that I would like to avoid a cesarean delivery If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making. I would like (coach) to be present during the surgery. Please explain the surgery to me as it happens. I would prefer general anesthesia in an emergency only. I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery. I would prefer spinal anesthesia for the procedure. I would like to have a respectful atmosphere without chatter during any part of the surgical procedure. Please do not strap my arms to the table during the procedure. If conditions permit, I would like to be the first to hold the baby after the delivery. If possible, I would like to breastfeed the baby immediately after the birth. If conditions permit, the baby should be given to (coach) immediately after the birth. I would like our plans outlined here for after the birth to be followed as closely as possible. Please lower the screen just before delivery so I may see the birth of the baby. Newborn Care I would like to hold the baby skin-to-skin during the first hours to help regulate baby's body temperature. I would like to hold the baby through delivery of the placenta and any repair procedures. Please evaluate and bathe the baby at my bedside. If possible, please evaluate the baby on my abdomen. If the baby must go to the nursery for evaluation or medical treatment, (coach), or someone I designate, will accompany the baby at all times. I would prefer to bathe the baby myself, at my discretion. Please delay eye medication for the baby until we are well past the initial bonding period (an hour after the birth). I would like to waive the administration of eye medication. (Check with state laws) I would prefer erythromycin eye treatment to silver nitrate. I would like to waive the administration of routine Vitamin K, unless medically indicated. (Check with state laws) I would like to defer the PKU screening. I would like to defer the following vaccinations; 1) 2) 3) Postpartum I would prefer not to be catherized until I've had some private time to attempt urination on my own. If available, I would prefer a private room. I would like to have the baby room-in with me at all times. Once I've had time to recover, I would like the baby to room-in with me. I would like the baby to room-in with me during the day, but stay in the nursery at night. I would like the baby in the nursery at night, but brought to me for breastfeeding on demand. I would like the baby in the nursery and brought to me on request and for breastfeeding. I would like my (coach) to room-in with me. I would like (other) to room-in with me. I would like my other children to have free visitation access. Assuming I feel up to it and the baby is healthy, I would like to be released from the hospital as soon as possible following the birth. I would like permission for access to my chart and the baby's chart. Breastfeeding I plan to breastfeed and want to nurse immediately following the birth. Please do not give the baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity. Unless I am unable to give my consent, please do not give the baby any supplements without first informing me of the reason(s) and seeking my consent. Please do not give the baby a pacifier. I would like to know more about breastfeeding. I would like to meet with the staff lactation consultant. Additional notes I would like to take still photographs during labor and the birth. I would like to make a videorecording of labor and/or the birth. I am planning on leaving the baby boys genitals intact (No circumcision). First Stage of Labor Environment: Dim Lights Peace and Quiet Music Wear my own clothes No students, residents, etc. Minimal vaginal exams (Vaginal exams can actually cause problems such as infection and premature rupture of membranes.) Other (Please specify): Mobility Maintain mobility (Walking, rocking, up to bathroom, etc.) Freedom to move in bed only (up to the bathroom) Mobility not important (catheter, used with regular epidural) Hydration No restrictions (Eat & drink to your comfort) Clear Fluids (Water, Juice, Pregnancy Tea, Ice chips, Jell-O®, etc.) Heparin/Saline Lock (Can be used in place of an IV for administration of antibiotics for complications such as MVP or Group Beta Strep.) IV (You will have to have this if you are receiving medications.) Monitoring You may choose intermittent or continuous monitoring, condition of labor permitting. Intermittent Monitoring (ACOG Standards) Fetoscope (Special stethoscope for pregnant moms.) Doppler External Electronic Monitor Continuous Monitoring External Electronic Monitor Internal Electronic Monitor Pain Relief Only if I ask (Recommended if you are planning on not using medications, although you can still receive medications at any point.) Offer if uncomfortable Pain Relief Options Non-Medicinal Relaxation Positioning Water (Shower or tub) Heat or Cold Therapy Massage Acupressure IV medication Stadol Nubain Demerol Other Epidural Ultra low dose Epidural (Walking epidural) Induction/Augmentation Usually induction and augmentation will not be discussed in a birth plan. If you have choosen or required an induction then the decision will usually be made before you ever arrive at your birth place. However, it is important to know that you do have options. Induction Natural Methods (Walking, nipple stimulation, sex, etc.) Herbal Inductions (Cohoshes, etc.) Prostaglandin gel Pitocin (Given in IV, it is a synthetic hormone to induce contractions. Amniotomy (Breaking the amniotic sack). Cytotec (Oral or vaginally inserted tablet, more effective and costs less than pitocin, in most cases.) Augmentation Walking Nipple stimulation (Nipple stimulation releases natural oxytocin which will produce contractions.) Pitocin (Given in IV, it is a synthetic hormone to strengthen contractions.) Other (Please specify): Second Stage Pushing Some of these will depend on if you are medicated, how your labor is going, and the health of your baby. Choice of positions (Certain positions are better for encouraging a baby to come down.) Prolonged Length (There are still "time limits" in some places, where you will have a cesarean/forceps delivery if time is up.) Spontaneous Bearing Down (Listening to your body and pushing.) Directed Pushing (Being told to push at certain times, while holding your breath.) Prefer to use people for leg support (As opposed to stirrups or foot pedals.) Foot Pedals (These are at the foot of the bed and allow you to sit up straight while pushing, as opposed to laying back with the stirrups.) Squat/Birth Bar (This goes across the top of the bed, allowing you to lean on the bar as opposed to relying on people or footpedals and stirrups.) Stirrups (Used in long second stages and with epidurals.) Perineal Care Episiotomy is a tough issue, some women wish to avoid an episiotomy even if it looks like they will tear, while others would simply prefer to have an episiotomy. You may also leave this blank if you do not have a preference. Prefer No Episiotomy (Massage, compresses, positioning, etc.) (Select this one if you would prefer no episiotomy but not to the point of tearing.) Prefer to Tear (Massage, compresses, positioning, etc.) (Select this option if you would prefer to tear than have an episiotomy.) Episiotomy Pressure Episiotomy (Done without anesthesia, although you cannot feel it due to the pressure from the baby's head.) Local Anesthesia (for repair) Baby Care Cord Cutting Choose one for timing and select partner if you wish that option. Immediate (Sometimes done because the cord is around the neck or because the parents have no preference.) Delayed (Some parents prefer that the cord not be cut until after it has stopped pulsating so that the baby receive all of the blood from the placenta.) Partner (or labor coach) to cut cord. Eye Care Choose only one. None (In some states it is the law, in others it isn't, or if you sign a waiver.) Delayed (Most parents prefer to have the procedure delayed until after the initial bonding time is over, so that the baby can see clearly. It also depends on the types of medications used.) Immediate Feeding Baby Choose one feeding method, and you have an addtional option for pacifiers. Breast feeding only Bottle feeding only Combination No pacifiers or glucose water Separation Choose only one, although you can change your mind after the birth. None Delayed (after recovery period) Partial Rooming-In (Baby with mother during day, but not night.) Nursery (baby brought to you on your schedule.) Circumcision Please choose only one category or leave blank if your baby is a girl. None (Check here if you do not intend to have the baby circumcised, or if you do not intend to have him circumcised at the birth place.) Do not retract the foreskin In the Hospital Parents Present Use anesthesia (type depends on the practitioner) Other Baby Care Requests Cesarean Surgery You may only choose one form of anesthesia, and that is really up to the physician at the time. The other options are in the event of a planned, unplanned/non-emergent cesarean surgery. Planning a Cesarean Spinal/epidural anesthesia General anesthesia Partner Present Doula Present Video/Pictures Screen lowered to view birth Description of surgery Touch the baby Partner to cut cord Breast feeding in recovery room Other (Please specify): Sick Infant Choose as many as you would like. Breast feeding as possible Unlimited visitation for parents Handling the baby (holding, care of, etc.) If baby is transported to another facility, move us as soon as possible Other (Please specify):  Back to Babymoon Page