My Due Date:
January 13, 2012
My Address: ~
Child’s Father: ~
As long as the baby and I are healthy, I would like to have no time restrictions on the length of my pregnancy.
I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan.
If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced.
Please obtain my permission before stripping my membranes during a vaginal exam.
I prefer to have no vaginal exams until I go into labor.
During a vaginal exam, I prefer at no time to have my membranes broken unless there is an emergency situation.
I would like no internal vaginal exams, within reason, during my labor until I have an urge to push.
If induction becomes necessary, I would like to try natural induction techniques first (with the guidance of my practitioner).
These are the natural induction techniques I would like to try:
I request the following people to be present during my labor and/or 2nd stage labor:
I prefer to give birth in a birthing room.
I prefer to give birth in room with a shower and/or bath.
If birth equipment is available, I would like to use:
A birthing bed.
A birthing ball.
A bean bag chair.
A birthing tub/pool/shower.
A birthing stool.
A squatting bar.
Miscellaneous environmental requests:
I would like to have dimmed lights.
I would like for people entering the room to speak softly.
I am prepared to try to handle pain with these natural and alternative methods:
Other considerations :
Ultimately, I want to be able to walk around and move as I wish while in labor.
Ultimately, I would like to feel unrestricted in accessing any sounds of chanting, grunting, or moaning during labor.
***Please keep my door always closed during labor.***
I would like my baby and I to be intermittently monitored to allow for as much mobility as possible
As long as the baby and I are healthy, I prefer to have no time limits on pushing.
I would like to be encouraged/unencumbered to try the following different positions for labor:
Hands and knees.
On the toilet.
Whatever feels right at the time
I do not want to have an enema administered.
I prefer to have no episiotomy and risk tearing (unless I’m having a medical emergency).
To help prevent tearing, please apply:
Encourage me to breathe properly for slower crowning.
Other labor considerations:
If possible, please allow the shoulders and body of my baby to be born spontaneously, on their own.
I would like my partner or my mother to catch my baby.
I would like for our baby to hear our voices first.
I prefer to have the lights dimmed for delivery or, if it is daylight, to access only natural light.
It’s important to me to push instinctively. I do not want to be told how or when to push.
After Baby is Born:
As long as my baby is healthy, I would like my baby placed immediately skin-to-skin on my abdomen with a warm blanket over it.
Please do not separate me and my baby until after my baby has successfully breastfed on both breasts.
Please delay all essential routine procedures on my baby until after the bonding and breastfeeding period (i.e., bathing).
***If my baby is healthy, I would like to hold my baby and nurse it immediately in recovery.***
As long as my baby is healthy, I would like my partner to be the baby’s constant source of attention until I am free to bond with it (i.e., holding, skin-to-skin contact, etc.).
Please wait for the umbilical cord to stop pulsating before it is clamped.
Please allow my partner or another family member to cut the umbilical cord.
I would prefer for the placenta to be born spontaneously without the use of pitocin, and/or controlled traction on the umbilical cord.
I would like the option of taking home the placenta.
If the baby has any problems, I would like my partner to be present with the baby at all times, if possible.
I would like to have routine newborn procedures delayed until bonding and breastfeeding have occurred.
I would like all newborn routine procedures to be performed in my presence.
Administration of Eyedrops:
Please do not administer eye drops to my baby, I am willing to sign a formal waiver if need be.
Please do not administer vitamin K to my baby, I am willing to sign a formal waiver if need be.
PLEASE DO NOT ADMINISTER immunizations to my baby. If I choose to decide to I will do so at a later time.
We would like to give our baby his/her first bath using our own non-toxic baby products.
***Please do not circumcise him.***
We would like to wait, and delay the PKU testing until we are ready to leave the hospital.
My baby is to be exclusively breastfed.
Do not offer my baby the following without my consent (or at all):
Any artificial nipples.
If my baby’s health is in jeopardy, I would like:
To be transported with my baby if possible.
My partner to go with the baby.
To breastfeed or express my milk for my baby.
To have as much bodily contact with my baby as possible.
To be offered a room at the hospital for the duration of my baby’s stay (within reason).
I would like my in-hospital routine to be:
***Full rooming in, no separation, no exceptions, unless otherwise discussed.***
Other hospital preferences:
I prefer a private room.
I prefer to have my partner stay with me for the duration of my hospital stay.
I would like my other children (regardless of age) to be allowed to visit with me for as long as they wish.
My desire is to have a peaceful birth that is as calm and as spiritual as possible, given the surroundings and circumstances. It is my hope that there are little to no interventions and that my natural lifestyle is fully respected. I hope the hospital personnel is able to work cooperatively and harmoniously with myself and my baby in order for me to have the best possible experience. Ultimately, I do not want to regret my decision to trust my pregnancy and delivery with this health system. Many thanks for the perusal and consideration of this plan. : )