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Sample Birth Plan for a Natural Hospital-Based Birth

Preferences for Labor and Birth for (Name of Patient) (Strep B+: Yes/No)

Patient of (Name of Doctor/Midwife)

We have created this birth plan in order to outline some of our preferences for birth. We understand that there may be situations in which our choices may not be possible. We want and have the right to be informed of any procedures in advance, and to be allowed the chance to give informed consent. Thank you!

Labor

I would like to be free to walk and eat/drink as needed or desired (Hep-lock and intermittent monitoring preferred).

Please do not offer anesthesia unless I ask for it. If I ask, please first offer alternative choices for coping with pain.

I would like to avoid all narcotics, if possible.

If augmentation is required I would like to try alternative means to Pitocin unless it becomes medically necessary.

Please do not rupture my membranes unless medically indicated.

Delivery

Even if I am fully dilated, & assuming our baby is not in distress, I would like to wait until I feel the urge to push.

I prefer to push/not push according to my instincts and prefer not to have coaching in this effort.

I would like to push and deliver in a semi-reclined (45 degree) position or any position I prefer at the moment.

I would rather tear than have an episiotomy, unless medically indicated for myself or our baby.

Please allow the umbilical cord to stop pulsating before it is cut.

I prefer to wait for a spontaneous placenta delivery and do not want an injection of pitocin/tugging on my placenta.

Immediately after the birth, as per new AAP Guidelines:

Place our baby on my stomach/chest immediately after delivery and cover us with blankets/sheets

Allow us to remain in contact with our baby throughout the immediate postpartum period.

Perform the following procedures on my abdomen: Dry baby, Apgar scores, ID bracelets, physical assessment.

Delay the following procedures at our discretion up to 1 hr: Weigh, measure, needlesticks, vit. K, & eye prophylaxis.

Please leave the vernix on the baby's skin.

Other:

If our baby must go to the nursery for evaluation/medical treatment, my husband will accompany the baby.

Please do not bathe the baby, I would prefer to bathe our baby myself.

Please do not give our baby any nutritional supplements without first seeking my consent. If I am medically-unable to give consent, only provide baby with an elemental formula as food allergies run in our family.

Please do not give our baby a pacifier.

Thank You!

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Note on Cesarean Section Delivery:

I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.

If possible, please do not strap my arms to the table during the procedure.

Please lower the screen just before delivery so I may see the birth of the baby.

If possible, I would like to hold/breastfeed our baby immediately after the birth. If not possible, give the baby to my husband for the remaining duration of the surgery.