Pregnancy from Amazing Pregnancy


Title For Your Birth Plan
Birth Plan
Birth Preferences
Our Wishes for Childbirth
My Wishes for Childbirth
Regarding Labor and Birth
My Birth Plan
Other title
          Other title to use:
About You
Your first name:
Your middle name:
Your last name:
Your partner's name:
Your doula's, coaches, main supporter's name:
Other supporter's name:
Your health care provider's name:
Your due date:

Check here if you want your birthplan displayed on the screen so you can print it from your browser.
Location Of Birth
Where Will The Birth Take Place
     Hospital
     Birth Center
     Home Birth
     Other location
          Enter other location for the birth
Special Notes
I have tested positive for Group B Strep.
My blood type is Rhesus Negative.
I have gestational diabetes.
I am a diabetic.
My hearing is impaired.
My vision is impaired.
Other Special Notes:
General Comments
Introduction and Philosophy:
I would like all staff to discuss all procedures with my partner/coach and myself before they are performed.
I would like to be able to vocalize during labor and birth without criticism or comment.
I would like permission to see my chart and the baby's chart.
Other Comments:
Environment
I would like the room to be quiet during labor.
I would like it if non-essential personnel, including interns and
students were not present.
I would like a private birthing room.
I would like my partner to be present at all times.
I would like to wear my own choice of clothes.
I would like a private phone to be available.
I would like my supporters to be able to take photographs of the labor and delivery.
I would like my supporters to be able to video the labor and delivery.
I would like to listen to my choice of music during the labor.
I would like the lights to be dimmed during the labor.
I would like to use aromatherapy during labor.
I would like to have massages during labor.
I would like people to respect my privacy by knocking
before entering the room.
During The Labor
I would like vaginal examinations to be kept to a minimum.
I would prefer to avoid an IV unless it is necessary.
I would like to deliver in whatever position is comfortable for me.
I would like to be able to walk around during the labor.
I would like to be able to drink fluids during the labor.
I would like to be able to eat light foods during labor.
I would like to wear my glasses or contact lenses during the delivery.
I would like a mirror so I can see the baby's head during delivery.
Monitoring
I do not wish to have continuous fetal monitoring unless it is necessary.
I prefer external monitoring to internal monitoring.
I would like continuous fetal monitoring.
I would prefer to be monitored using a fetoscope.
I would prefer to be monitored using Doppler.
I would prefer to be monitored using an external electronic monitor.
Pain Relief
I would like to give birth naturally without medication and use the following methods:
     Bradley Method
     Lamaze
     Water:
          I would like to use a birthing tub for pain relief.
          I would like to use a shower for pain relief.
     The Alexander Technique
     Massage
     Acupressure

I would like to give birth naturally , but would like the following medication to be available should I require it:
     Stadol
     Nubain
     Demerol
     Low dose Epidural
     Epidural Block

I would like the following pain relief medication to be administered as soon as possible:
     Stadol
     Nubain
     Demerol
     Low dose Epidural
     Epidural Block
Induction
I would like to avoid induction unless there are signs of fetal distress.

Before induction, I would like to try the following natural methods to progress labor:
     Relaxation
     Herbs
     Nipple stimulation

If induction is necessary, I prefer the following methods:
     Pitocin
     Prostaglandin Gel
     Amniotomy
     Cytotec
Episiotomy
I would prefer to avoid an episiotomy, even if tearing is possible.
I would prefer to avoid an episiotomy unless tearing is possible.
I would like an episiotomy.
Delivery Of The Placenta
I would like medication to aid the delivery of the placenta.
I would like to deliver the placenta naturally.
I would like to inspect the placenta after delivery.
Caesareans
I would like to avoid a caesarean unless it is absolutely necessary.
I would like a second opinion before having a caesarean.

I would like the following anesthesia for a ceasarean:
     Epidural
     General Anesthesia

I would like my partner/coach to be present during the caesarean.
I would like my partner/coach to take photographs during the caesarean.
I would like my partner/coach to video the caesarean.
I would like the screen lowered so I can view the birth.
I would like to touch the baby as soon as possible.
I would like my partner/coach to cut the cord.
After The Birth
I would like the baby handed to me immediately it is born, unless there are signs of fetal distress.
I would like to have the baby evaluated in my presence.
I would like to cut the cord myself.
I would like the umbilical cord to stop pulsating before it is cut.
I have made arrangements to donate the umbilical cord blood.
I have made arrangements to bank the umbilical cord blood.
I would like my partner/coach to cut the cord.
I do not wish to cut the cord.
I would like my baby to be kept with me at all times.
Feeding
I would like to breast feed my baby.
I would like to bottle feed my baby.
I will use a combination of breast feeding and bottle feeding.
Please do not give the baby supplements, pacifiers or glucose solution without consulting me.
In The Event The Baby Is Sick
I would like to breastfeed where possible.
I would like unlimited visits for the parents.
I would like to hold the baby where possible.
If it is necessary to transfer the baby to another facility, I would like to follow as soon as possible.
Circumcision
No circumcision is to be performed.
Do not retract the foreskin.
Circumcision can be performed in the hospital.
Anesthesia must be used for the circumcision.
I would like to be present at the circumcision.
Eye Care
I decline eye care for my baby.
I would like to delay eye care until after I have bonded with the baby.
I would prefer erythromycin eye treatment to silver nitrate for my baby.
Vitamin K
I decline vitamin K for my baby.
I would like vitamin K to be administered to my baby.
I would like vitamin K to be given orally.
         
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