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Birth Plan for First Middle Last
Due Date: 1/25/06
Patient of Dr Jane Doe
Scheduled to deliver at Medical Center.
12/12/05
Dear Dr Doe and the Medical Center Staff:
I look forward to sharing my upcoming birth with you. I have created the following birth plan to help you understand my preferences for my upcoming labor and delivery. I fully understand that in certain circumstances these guidelines may not be followed, but it is my hope that you will assist me in making this the experience I hope for. If you have any questions or suggestions, please let me know.
Sincerely,
First Last
Labor
I would prefer to avoid an enema and/or shaving of pubic hair.
I wish to be able to move around and change position at will throughout labor.
I would like to be able to have fluids by mouth throughout the first stage of labor.
I would prefer to keep the number of vaginal exams to a minimum.
Monitoring
I do not wish to have continuous fetal monitoring unless it is required by the condition of my daughter.
Labor Augmentation/Induction
I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring.
I would prefer to be allowed to try changing position and nipple stimulation before pitocin is administered.
Anesthesia
I do not want any kind of anesthesia offered to me during labor, though would like it available if I specifically request it.
Custom note regarding use of an epidural
Cesarean
If my primary care provider determines that a cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows.
I would like my husband present at all times if my daughter requires a Cesarean delivery.
I wish to have an epidural for anesthesia
If my daughter is not in distress, my daughter should be given to (blank) immediately after birth.
Episiotomy
I would prefer not to have an episiotomy unless absolutely required for the baby's safety.
Delivery
I would like my husband and/or nurses to support me and my legs as necessary during the pushing stage.
I would like a mirror available so I can see my daughter's head when it crowns.
Even if I am fully dilated, and assuming my daughter is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.
I would like to have my daughter placed on my stomach/chest immediately after delivery.
After Delivery
I would like to cut the cord myself.
I would like to have my daughter examined and bathed in my presence.
If my daughter must be taken from me to receive medical treatment, my husband or some other person I designate will accompany my daughter at all times.
I would like a private room if available.
After the birth, I would prefer to be given a few moments of privacy to urinate on my own before being catheterized.
I would like to donate the umbilical cord blood.
Breastfeeding
Unless medically necessary, I do not wish to have any bottles given to my daughter (including glucose water or plain water).
I do not want my daughter to be given a pacifier.
Photos
I would like to make a videorecording of labor and/or the birth.
Other
My support people are my doula and I would like them to be present during labor and/or delivery.
