Mom's Name: mom
Dad's Name: Dad
Doula: Jodilyn Owen
Estimated Due Date: now
My doctor is: Dr. I Trust

Dear Nursing Staff,
We have created this birth plan to help you understand our preferences for labor and delivery and post-natal care. We fully understand that in certain circumstances these guidelines might not be followed, but it is our hope that you will assist us in making this the experience we desire. If you have questions or suggestions, please let us know.

I plan on laboring without medication and would appreciate working with a nurse who has experience and enjoys working with such births. 

Thank you,

MomandDad To-be

During Labor, I would like to

I prefer to be monitored

Labor Augmentation Options

·         walk around

·         use the birth ball and position changes as needed

·         eat to hunger and drink to thirst

·         keep the lights dimmed

not have an IV attached to me.  if I need it for GBS, I would like a heplock left in and attached only as needed to administer the antibiotics

·         the minimum time required

·         with a Doppler or fetoscope

·         I do not want internal monitors placed unless medically necessary

·         If I am not in active labor, please send me home

·         I would like privacy to use nipple stimulation before I would want to talk about Pitocin

if my labor is at a point where you think that artificially rupturing the waters will help it along, please discuss this with me

Pain Medications

Pushing Preferences

Delivery Preferences

·         I do not want to use narcotics—they make me feel unwell

·         I took care to educate myself about the options of pain medications, and I am choosing to labor and birth without them.  If I change my mind, I’ll let you know but please don’t offer them to me.  I understand that it takes time to get them if I decide I want them.

·         I would like to push in whatever position feels most comfortable to me at the time

·         Please offer me the squat bar on the bed for the delivery

·         Please have mineral oil and warm cloths ready to help support and my perineum while it stretches

·         I would not like an episiotomy unless there is a medical emergency

·         Please deliver my baby right to my stomach

·         It is very important to us that the cord stop pulsing before it is cut

·         Dad would like to cut the cord

·         I would like the baby to stay with me and nurse for a while before it is weighed and measured

·         If necessary,  Dad will go with the baby to the NICU

Caesarean Preferences

·         I prefer to avoid a caesarean section and appreciate any help or advice you have along the way to help me with this

·         I would like my primary OB to discuss the necessity of a caesarean with me if that arises

·         If I have a caesarean section, we would like our Doula in the O.R. with us

·         Because research shows there is so much benefit to the baby, I would like the cord to stop pulsing before it is cut

·         As soon as the baby can, we would like Dad to hold him

 

Breastfeeding Preferences

·         I plan to breastfeed on demand

 

Other

·         We have chosen not to have our baby use the prophylaxis eye ointment

·         You may administer the vitamin K shot