Birth Plan for *mother's_name_here* Submitted to: All Attending Caregivers Submitted by: *Birthing mother and father name goes here* Birth Plan for *mother's_name_here* Address *here* My Health History Number of Pregnancies: Number of Births: Problems during previous pregnancy: Problems during this pregnancy: Illnesses during this pregnancy: Allergies: Current Drugs/Medications: (Include any alerts which medical personnel must be aware of, for example: ALERT: No blood drawn, no blood pressure taken, no I.V. in right arm!) Preferences for Labor and Delivery These are my preferences for my labor and delivery. I expect that my caregivers and the hospital or birth center will make every effort to follow this plan; however, I understand that circumstances may arise which necessitates changes in the plan. I request that any changes be discussed with me and/or my husband. I have discussed this plan with my midwife. I want my husband with me during labor. I want my midwife, midwife's-name-here, with me during labor and any necessary procedures. My husband and I have attended childbirth education classes together. I prefer that the following procedures NOT be used unless absolutely necessary, and then only upon consultation with me and my husband: I.V. pubic shave electronic fetal monitoring forceps vacuum extraction administration of oxytocin administration of Demerol, Phenergan, or other narcotics epidural anesthesia episiotomy During Labor - I WOULD like: complete freedom of movement to use breathing and relaxation techniques massage by my support persons herbs and teas provided by my support persons to be able to take showers my support persons with me throughout to drink and eat as desired the use of a fetal stethoscope I do NOT want: medications administered enemas catheterization During Delivery - I WANT: the least intervention possible my support persons with me throughout to be free to try different positions I do NOT want: to deliver lying flat on my back or semi-reclined the administration of analgesics or anesthetics If a cesarean delivery becomes necessary: I want my husband and midwife with me throughout Skin incision: bikini Uterine incision: horizontal/vertical ???? Other Special Needs for Delivery ___________________________ After Delivery: I do NOT want any vaccinations administered to me or my baby. If my baby is a boy, there will be NO CIRCUMCISION performed. No liquid will be fed to my baby other than my breast milk - no water, no glucose. My husband wants to cut the umbilical cord. I want the umbilical cord allowed to drain and not cut immediately. I want my baby put to my breast immediately after birth. I want routine testing done while I'm holding my baby. I want to hold my baby for at least one hour before any routine tests are performed. I want my husband to accompany my baby to any other locations. I want to breastfeed immediately. I do not want my baby washed off. I want 24-hour rooming in and to provide my baby demand feeding.. Any eye drops or tests should be delayed until my baby is falling asleep. Allow baby to handle mucus by itself before suctioning. Allow time for natural delivery of placenta. No uterine stimulant. Unexpected Surgery______________________________________ I want my husband and midwife present throughout. I would like an alternative to general anesthesia. I would like any screens lowered or my baby held up for me to see. I want to continue wearing my glasses. I or my husband should hold baby if my baby is not in distress. I will be allowed to breastfeed my baby if our conditions permit. - - BEFORE PRINTING: After filling out your Plan delete these instructions - - - - - -- - -- - ·Customize this Plan according to your needs/desires. ·Insert your actual name, address, etc. ·Add or delete items according to your needs ·Bold or un-bold text according to your priorities. ·After customizing and completing, reformat your pages so that no list is interrupted by a page break. ·It is advisable to copy the header lines (Birth Plan for…, Submitted To…, and Submitted By …) to the top of each page. ·Staple completed pages together. ·Copies should be given to your midwives and/or obstetricians in advance of delivery. ·Have copies with you at the hospital.