back	samples 1 2 3 4 5 6 7 8

Mother-to-be: _____________ Partner: ___________
Support Person(s): _____________ Due Date: _______
Practitioner: _______________ Place of Birth: _____________

This birth plan is intended to express the preferences and desires we have for the birth of our baby. It is not intended as 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 guide us toward the birth experience we desire.

If procedures or medications are proposed, we ask that you discuss them with us and suggest alternative therapies and comfort measures so that we can make well-informed decisions.
We are striving for flexibility on our part, as well as that of the birth team.

Also, because I am a sexual abuse survivor, there may be special emotional issues that may present during labor and delivery that I am not prepared for. I have been diagnosed with Post Traumatic Stress Disorder and anxiety, and am prone to panic attacks. Being aware of this, I have been working with a therapist, trained in hypnosis, on calming and self-soothing (hypno-birthing) for the last trimester. I have also taken Lamaze classes, practiced prenatal yoga, walked several miles per day, and generally prepared for birth in every way possible.

The following are our optimal choices for birth.
First Stage (Labor):
· Would prefer my own clothes.
· Would prefer to keep medical staff to a minimum.
· Would prefer to keep vaginal exams to a minimum.
· Maintain mobility (Walking, rocking, up to bathroom, etc.)
· Clear fluids and ice chips.
· Positioning as desired.
· Heparin lock, if needed.
· Intermittent Monitoring (ACOG Standards) with EFM.

Please do not offer me pain medications, I will ask for them if I want them. These may include: IV Demerol or ultra low dose epidural (walking epidural) unless medically impossible.

RELAXATION TECHNIQUES:
o Breathing, Focusing, etc
o Water: would like to use the birthing tub and/or shower
o Heat or Cold packs.
o Massage (back, foot, counter pressure, etc.).
o Acupressure

Free Movement: I would like to be able to move around and change position at will throughout labor. I would like to be allowed to choose the position in which I give birth, including squatting or on my hands and knees.
Birthing Tub: I am aware that _____ hospital has a birthing tub and birth balls, which I would like to use.
IV: I would prefer not to have an IV. If necessary, I will accept having a heparin lock in place.
External Fetal Monitoring: We expect that you will need to monitor me upon arrival, but we request that monitoring be intermittent thereafter.
Prep: I would prefer to avoid an enema or extensive shaving of pubic hair.
Artificial Rupture of Membranes: I do not wish to have the amniotic membrane ruptured artificially before the birth unless signs of fetal distress require an internal monitor.
Induction: I would prefer to use natural methods to start labor.
Anesthesia and Pitocin: I do not wish to use any anesthesia unless I request it during labor. I do not want routine Pitocin to induce or augment labor or after the birth. Please allow us to try natural induction methods, and to breastfeed immediately to avoid any chance of hemorrhage.

Second Stage (Birth):
· Choice of position
· Spontaneous Bearing Down
· Birth/Squat Bar
· I would rather tear than have an episiotomy, but please use compresses, massage and positioning.

Episiotomy: I do not wish an episiotomy unless required to avoid an extensive tear. I would prefer a medium-sized tear to an episiotomy.
Baby Care:
· Delay the cord cutting until it has stopped pulsing so the baby can receive all the placental blood
· Prefer husband Rob to cut the cord.
· Delay the eye medication
· Breastfeeding only, and within ½ hour of delivery if possible
· No pacifiers or glucose water (to avoid nipple confusion)
· No separation of Mother & Baby
Birth: I would like to be allowed to hold the child immediately after birth, skin-to-skin. We would prefer that the cord not be cut immediately, but given a few minutes to cease functioning first.
Breastfeeding: I intend to breastfeed and do not wish to have any bottles given, including glucose water.
Rooming-in: We would like to have the baby remain with us in our room after birth. This is very important to us. ** We do not want the baby to be taken away from us unless she requires medical treatment, or unless we request to have her taken to the nursery. We would like to have the baby examined in our presence.
Corrective Lenses: I need to wear contact lenses or glasses at all times when conscious. I wear extended wear contact lenses, and my husband will have my glasses in case I need to remove my lenses.
Cesarean Birth: I wish to have an epidural for anesthesia, and to have my husband and doula present for the birth, if possible. The child, if she is not in distress, should be given to my husband.
• Spinal/epidural anesthesia
• Partner and Doula present
• Partner to cut the cord
• Breast feeding in recovery room
Sick Baby:
• Breast feeding as soon as possible
• Unlimited visitation for parents
• Handling the baby (Kangaroo care, holding, care of, etc.)
• If the baby is transported to another facility, move us as soon as possible