This is the one that I used last time. I had to have copied it from somewhere and added and subtracted some stuff. I may have found it here :) I did not end up needing it and decided not to write one this time.
Mother: Father: Baby:
Expected Due Date: May 30, 2011
Practitioner: ______________, CNM
Our primary goal is a healthy mother and healthy baby. We believe birth is a normal physiological event and an inherently safe process, and were therefore planning a home birth. We realize labor doesn’t always progress as planned, and although we hoped to still be at home, we are happy and grateful to transfer our care at this point. We desire a non-medicated labor and birth, limiting the use of medical interventions to that necessary for treatment of an abnormality or complication. We understand that complications can arise unexpectedly, and are grateful for the expertise of our doctors, midwives and the nursing staff, and the technology available to assist us in that event.
In the absence of an emergency we ask that the following requests be honored:
Labor and Birth
- We wish to be fully apprised and consulted of all risks and benefits before the introduction of any medical procedures or intervention.
- We ask that all members of our birthing team remain with us at all times. Because we are a home birth transfer, this includes our midwife and/or any of her assistants that accompany us to the hospital, whose primary task will be to assist us
- I would prefer not to have an episiotomy unless it is absolutely needed for the baby’s safety.
- Unless there is excessive bleeding we would prefer not to have routine pitocin after delivery
- Unless our baby is in crisis, we wish for her to be delivered directly onto the mother’s abdomen and remain there for bonding and immediate breastfeeding.
- Please do not allow any visitors at any point in time without asking my permission first
- Our baby will be breastfed on demand. We ask that, to help us establish successful breastfeeding, no rubber nipples, sugar water, pacifiers, etc be given.
- Unless there is a serious medical condition requiring advanced care, we desire continual ‘rooming-in’ with our baby and no mandatory time in the nursery to promote breastfeeding and bonding. If exams, etc, must be done in the nursery, at least one parent will accompany the baby to the nursery and remain there during the exam/procedure.
- We do not wish for the baby to be bathed in the hospital or by hospital staff. We prefer to wipe the baby down with warm towels or blankets immediately after birth to dry her and for us to bathe our baby for the first bath at home.
- We would like the option of early discharge for mother and baby assuming there are no over-riding health concerns. We would like to avoid an overnight stay if possible, and would prefer to limit our hospital stay to 12 hours post-partum.
- Our baby is a boy (according to ultrasound) and we would like for him to be circumcised.
In case of C-section
- A double row of stitching should be used so that I can birth vaginally in the future
- I would prefer that my husband or another member of the birth team remain with me at all times. I have anxiety and this would be in everyone’s best interest.
- Any medications used should be compatible with breastfeeding
- We would appreciate being kept informed during the surgery
- If the baby is healthy, please allow the baby to stay with me along with my husband or birth team until surgery is finished.
- I would like to be able to breastfeed as soon as possible after the surgery
We trust your judgment and know you will help us have the best birth experience possible, and thank you, nurses, midwives and doctors of this hospital, in advance for respecting our preferences for this natural and beautiful process. We are excited for this adventure and feel lucky to have your help, support and guidance.