back	samples 1 2 3 4 5 6 7 8

Birth Plan for ___________ and ________ __________

Dr. _____________
________________, Doula

My husband and the doula should be present with me throughout labor and delivery.

We respectfully request that there be as little intervention as possible, unless an emergency arises.

We would like to be part of the decision-making process… to be consulted with and asked for our consent before any medical procedure is performed.

We would prefer NOT to have the routine use of:

• IV (please use heparin lock if necessary)
• Frequent electronic fetal monitoring
• Medications for pain
• Pitocin for Labor augmentation
• Artificial Rupture of Membranes
• Frequent vaginal exams
• Episiotomy

We would like to have freedom of motion and a choice of laboring positions

Induction/Augmentation of Labor:
I would like for my labor to proceed at its own natural pace, and would therefore like to avoid measures such as amniotomy, stripping of membranes, and/or pitocin unless a specific medical need arises.

*Unless there is excessive bleeding, we prefer not to have routine pitocin administered after the birth.

Pushing
I would like to push spontaneously with the urge, not directed pushing.

Perineal Massage
I would like perineal massage done during the birthing process.

Episiotomy
We would like to avoid an episiotomy; if one is deemed absolutely necessary, we would like to try for a pressure episiotomy when the baby's head is crowning.

BABY
I would like rooming in 24 hours a day.
I would like the baby to be handed to my husband after the newborn procedures have been performed.
I would like to Breastfeed as soon as the baby and I are ready.
I would like to request that s/he not be given artificial nipples of any kind, including bottles (formula or water) or pacifiers.

Special Cases
In the case that a cesarean section needs to be performed, we would prefer not to have general anesthesia, allowing the mother to be awake and alert for the birth and the father and doula to be present.

If the baby should need special care, we want to be involved in that care as much as possible and want the baby breast-fed or given expressed mother's milk from a bottle.