Sample Plan 2

The Smith Family Birth Plan

Your Name(s)__________________________

Care Provider’s Name_____________________

Doula’s Name_________________________

Additional people you wish to have present at the birth

                        ______________________________

                        ______________________________

                        ______________________________

                        ______________________________

This birth plan is intended to express the preference and desires we have for the

birth of our baby. It is not intended to be a script. We fully realize that situations

may arise such that our plan cannot and should not be followed. However, we hope that barring any extenuating circumstances, you will be able to keep us informed and aware of our options. Thank you.

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, Gatorade®, Jell-O®, etc.)

Ice Chips

Heparin/Saline Lock (Most hospitals require this as access to a vein should an emergency occur, it can also be used in place of an IV for administration of antibiotics for complications such as MVP or Beta Strep.)

IV (You will have to have this if you are receiving medications.)

Monitoring:
You may choose intermittent or continuous monitoring.

Intermittent Monitoring (ACOG Standards)

Fetoscope (Special stethoscope for pregnant moms.)

Doppler

External Electronic Monitor

Continuous Monitoring

External Electronic Monitor

Internal Electronic Monitor

Pain Relief Offers:
Check only one.

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

Offer as soon as possible

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)

Classical Epidural

General Anesthesia (Extremely rare now for a vaginal birth.)

Other (Please specify):

Induction/Augmentation:
Usually induction and augmentation will not be discussed in a birth plan. If you have chosen 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 (Recommended if you have an "unfavorable cervix.")

Pitocin (Given in IV, it is a synthetic hormone to induce contractions.)

Amniotomy (Breaking the waters.)

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.)

Amniotomy (Breaking the waters.)

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 to cut cord

Eye Care:
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:
Breast feeding only

Bottle feeding only

Combination

No pacifiers or glucose water (This would be to avoid nipple confusion.)

Separation:
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:
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 (Depends on the practitioner)

Other Baby Care Requests

Other (Please specify):

Complications & Cesareans

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.

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
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):