|
Birth Plan
Sample
I
My Actual
Birth Plan
Below is a copy of my actual Birth Plan. It is included on
the main site. However, there it's in pdf format, which
doesn't allow you to easily edit it. If you'd like to use it
as a starting point for developing your own, then just copy and paste
it into a Word document and go crazy!
BIRTH PLAN
We have prepared this Birth Plan to help you understand our philosophy
and the kind of care we hope to have for the birth of our
child. We have chosen our doctor because he shares our desire
for a low-intervention birth and respects our need for good
communication. We expect, and trust, that our practitioner
will seek our opinion on all issues that may affect our birth
experience or that deviate from this plan. We wish for as natural a
birth as possible, avoiding unnecessary procedures and
medications.
We would like to direct, but know we cannot control, our childbirth
experience. When this Birth Plan is respected, then, if we
need to deviate from its general guidelines, we will feel better about
the change. Let us know right away if you think we need to
change plans, and why the change is necessary. We would like
to be part of the decision-making team and to be consulted about and
asked for our consent before any medical procedure is
performed. In addition, we would like any medical procedure
explained as it is performed. We fully realize that
emergencies can happen, and that in the case of an emergency, the
health care team will take the best steps for our family.
BIRTH TEAM
• It is important to us that we remain
together at all times during the labor and delivery (vaginal or
cesarean).
• While we understand and can appreciate
the need for training and teaching, we highly value our privacy and
would like to keep the birth team to the minimum necessary number,
which excludes residents, trainees, and other nonessential personnel.
PREPARATION
• ALLERGIC TO
PENICILLIN
• No routine enema
• No shaving or removal of pubic hair.
EARLY & ACTIVE LABOR
ENVIRONMENTAL CONDITIONS
• Lights dimmed
• Voices respectfully lowered
• Prefer option to film and/or photograph
POSITIONS
• Prefer freedom to choose positions and
activity level in labor as long as cord prolapse is not an issue.
PAIN RELIEF
• Pain relief through Hypnobirthing
relaxation techniques, breathing, massage, counter-pressure, changes in
position, water (tub/shower) and emotional support.
• No pain medications to be offered
unless requested.
• If available, I would like access to a
tub, squatting bar, birthing ball, and rocking chair.
FOOD
• Ice chips or light beverages upon
request.
FETAL MONITORING
• External fetal monitoring only as
required by the condition of the baby.
• We very much want to avoid internal
fetal monitoring unless it is specifically medically
indicated.
EXAMS
• Internal exams for specific medical
indication, when labor changes, or by request.
METHOD OF ELIMINATION
• Prefer to walk to the bathroom when
needed.
• If catheterization becomes necessary,
we prefer to have it removed as soon as possible after bladder is empty.
LABOR AUGMENTATION
• As long as the baby and I are fine, I
would like to be free of time limits and not have my labor augmented.
• If ROM occurs at onset of labor, I
prefer to wait 12 hours or more before inducing if our condition
permits.
• If necessary, I would like to try
walking, nipple stimulation, and pelvic rocking.
PUSHING & DELIVERY
POSITIONS
• Position in pushing phase to be
determined by me at the time (using gravity enhanced positioning if
possible— includes the possibility of full/partial squatting
positions—not flat on back).
• Pillows, wedge, elevated table back for
support at delivery, if necessary.
PAIN RELIEF
• Pain relief through Hypnobirthing
relaxation techniques, breathing, massage, counter-pressure, changes in
position, water (tub/shower) and emotional support.
• No pain medications to be offered
unless requested.
EPISIOTOMY
• Desire to try for intact perineum with
massage, support, and hot compresses.
• If necessary, we prefer a pressure
episiotomy when baby's head is crowning. (Small tear is preferable to a
large incision.)
• Local anesthetic is permissible for
performing & repairing an episiotomy.
EXPULSION TECHNIQUES
• As long as the baby and I are fine, I
would like to be free of time limits on pushing.
• Prefer option of self-directed pushing
to help ease the baby out slowly and avoid tearing the perineum.
• NO LAMAZE-TYPE PROMPTS-we are using
Hypnobirthing techniques.
• If pushing is not progressing
efficiently, I would like to be reminded that sometimes changing
positions helps. I would like to be encouraged to try one or
more of the following delivery positions: squatting, side-lying,
standing upright, hands and knees on floor, kneeling with arms resting
on bed/chair, or semi-reclining on bed-knees pressed to chest with
support person behind providing counter-pressure.
• Forceps preferable to vacuum
extraction, but prefer to avoid both if possible.
• Mother would like to be allowed to
touch the baby's head as it begins to crown if labor is normal.
• Mother would like to catch the baby if
baby’s condition permits.
BABY’S ARRIVAL
• Baby placed on my chest upon delivery.
• Father would like to cut the cord.
• Would like to nurse immediately after
delivery if possible.
• Prefer newborn procedures completed
after initial bonding time if possible.
• Prefer non-irritating eye agent, such
as erythromycin or tetracycline, as late as possible.
AFTER BIRTH/POSTPARTUM
• Prefer spontaneous placenta separation
with breast stimulation/nursing the baby after delivery rather than
inducing with pitocin, uterine massage or cord traction. If a
procedure is necessary, please explain it to me.
• Perineum ice packs if requested
immediately after birth.
• If fundal massage is necessary I'd like
to try it myself, with someone else instructing how.
• Prefer freedom of movement after birth.
• Prefer to avoid routine administration
of pitocin after the birth if possible.
RECOVERY/POST-RECOVERY
• Recovery with baby in private
• Please hold all phone calls until
otherwise instructed
• 24-hour rooming in
• Breastfeeding on demand with assistance
only as requested
• Prefer to have person of choice in my
room at any time of day
• We would like the option being
discharged as soon as possible once our obstetrician has approved it.
• If the baby is a boy, there will be no
circumcision.
BABY CARE
IMMEDIATE CARE
• Prefer to postpone routine newborn
procedures until we have had a chance to bond with our baby.
• Baby held by parents and nursed by
mother.
FEEDING
• Breastfeeding exclusively on demand
• NO supplementation of any
kind—pacifier, sugar water, formula, etc.
AIRWAY
• Suctioning if necessary
NEWBORN PROCEDURES
• Prefer all routine procedures done in
our room after initial bonding time if possible.
• If this is not possible, we would like
to have father stay with the baby at all times.
• We prefer that the baby be gently wiped
down with a soft cloth to remove fluids, and wrapped in a blanket.
• Please do not bathe, to allow our
baby's natural vernix to continue to soften and protect the skin.
• Prefer use of oral Vitamin K if
possible.
• We ask that you discuss any additional
newborn procedures with us before they are performed.
EYE CARE
• Prefer non-irritating agent, such as
erythromycin or tetracycline, as late as possible.
WARMTH
• If warming is necessary, prefer mother
holding baby, with soft cloth/blanket covering both.
CONTIGENCY PLANS
CESAREAN DELIVERY
• Please keep communication open. If at
all possible, please wait for my express consent, or that of my
husband, before initiating any procedure.
• It is important to me that my husband
be present with me at all times during the birth.
• Ideally, I would like to remain awake
and aware, avoiding general anesthesia if possible.
• Prefer regional anesthesia with little
or no premedication or discuss further anesthesia options with me.
• We prefer that the anesthesia take
effect before the catheter is inserted and that there are no "hot
spots" (areas which are not yet numb) before the surgery begins.
• Prefer to have the obstetrician
explains events as they occur.
• Please use a low-transverse incision on
my uterus and abdomen.
• Please leave at least one of my hands
free so I may touch our baby when he or she is born.
• Assuming the baby is well, I would like
to hold our baby on my chest.
• Breastfeeding as soon as possible.
• We would like the baby's health to be
judged on its own merits - no special nursery care unless necessary.
• Please remove my IV and catheter as
soon as possible following our baby's birth.
• Please provide me with nutritious food
and drink as soon as possible.
PREMATURE BIRTH/ILL BABY
• If our baby is not well, we would like
to:
• accompany my baby, or have the father
accompany our baby, if transported to another facility.
• breastfeed exclusively, or provide my
expressed milk for our baby.
• have unlimited visitation.
• hold, rock and care for our baby, if
possible.
• Visit NICU as much as possible.
• Have all procedures explained before/as
they are performed as our baby’s condition permits.
We thank you for taking the time to go over this Birth Plan, and
appreciate your cooperation in getting our new family off to great
start!
Physician
Date
Mother
Date
Father
Date
|
|