Here's mine - hope it helps.
Our wish is to have a homebirth free of medical interventions. This plan is written in the event that our baby arrives too early to deliver at home or if other complications arise leading to a hospital transfer. We appreciate your expertise in labor, delivery and care of a newborn and we ask that you help us maintain our wish of having as few interventions as possible.
Please get consent for all interventions or routine procedures you deem necessary. Please be ready and willing to explain all details and options available to us.
Labor and Delivery
·Please keep the labor and delivery room quiet at all times. Please keep voices low and conversation to a minimum.
·I will drink water and electrolyte drinks during and after labor so there will be no need for extra IV fluids.
·Intermittent fetal monitoring only.
·Do not insert an internal fetal monitor.
·I would like to move freely in labor and push in whatever position seems most comfortable to me at the time. I am open to natural and supportive suggestions for comfort and pain management. Please do not offer me pain medications or an epidural.
·Do not perform an episiotomy.
·Place the baby onto my chest and into my arms upon delivery.
·Do not clamp or cut the cord until it is discussed with me. Preferably after the placenta is delivered. Please offer Paul the option of cutting the cord.
Cesarean Delivery
·It is important that my husband and support people are with my son and me during the procedure.
·Please discuss anesthesia options with me. Ideally I would like to remain awake and aware during the delivery of my son.
·Please leave at least one of my hands free so that I may touch my son immediately after his birth.
·I would like to hold Reidar to my chest and begin nursing immediately.
·If it is necessary to take Reidar from me after delivery it is imperative that Paul (his father) be with him at all times and consulted about all procedures. My support people will stay with me.
Newborn Care
·Should Reidar need to be warmed we would like him skin to skin on mother or father covered with warm blankets.
·We would like all procedures performed with explanation and consent and either in the arms of mother or father.
·Please delay the routine procedures of antibiotic eye ointment and Vitamin K until bonding has begun and administer in the arms of mother or father.
·If blood draws are needed, Reidar will be held by mother or father, his foot down and warmed before the heel is pricked.
·Reidar will be exclusively breastfed. I welcome any assistance with this process. Do not give him any formula, bottles or pacifiers. Should supplementation become necessary he will be fed by a family member using a Supplemental Nursing System or finger feeding.
·NO vaccinations will be given in the hospital. Vaccinations will be discussed with and administered by our pediatrician.
·NO circumcision.
·We will give our son his first bath.
·We would like to remain rooming with our son at all times and to go home as soon as possible with our son. We are aware that extremely competent home health care nurses are available and would welcome the opportunity to use them if necessary.
Our wish is to have a homebirth free of medical interventions. This plan is written in the event that our baby arrives too early to deliver at home or if other complications arise leading to a hospital transfer. We appreciate your expertise in labor, delivery and care of a newborn and we ask that you help us maintain our wish of having as few interventions as possible.
Please get consent for all interventions or routine procedures you deem necessary. Please be ready and willing to explain all details and options available to us.
Labor and Delivery
·Please keep the labor and delivery room quiet at all times. Please keep voices low and conversation to a minimum.
·I will drink water and electrolyte drinks during and after labor so there will be no need for extra IV fluids.
·Intermittent fetal monitoring only.
·Do not insert an internal fetal monitor.
·I would like to move freely in labor and push in whatever position seems most comfortable to me at the time. I am open to natural and supportive suggestions for comfort and pain management. Please do not offer me pain medications or an epidural.
·Do not perform an episiotomy.
·Place the baby onto my chest and into my arms upon delivery.
·Do not clamp or cut the cord until it is discussed with me. Preferably after the placenta is delivered. Please offer Paul the option of cutting the cord.
Cesarean Delivery
·It is important that my husband and support people are with my son and me during the procedure.
·Please discuss anesthesia options with me. Ideally I would like to remain awake and aware during the delivery of my son.
·Please leave at least one of my hands free so that I may touch my son immediately after his birth.
·I would like to hold Reidar to my chest and begin nursing immediately.
·If it is necessary to take Reidar from me after delivery it is imperative that Paul (his father) be with him at all times and consulted about all procedures. My support people will stay with me.
Newborn Care
·Should Reidar need to be warmed we would like him skin to skin on mother or father covered with warm blankets.
·We would like all procedures performed with explanation and consent and either in the arms of mother or father.
·Please delay the routine procedures of antibiotic eye ointment and Vitamin K until bonding has begun and administer in the arms of mother or father.
·If blood draws are needed, Reidar will be held by mother or father, his foot down and warmed before the heel is pricked.
·Reidar will be exclusively breastfed. I welcome any assistance with this process. Do not give him any formula, bottles or pacifiers. Should supplementation become necessary he will be fed by a family member using a Supplemental Nursing System or finger feeding.
·NO vaccinations will be given in the hospital. Vaccinations will be discussed with and administered by our pediatrician.
·NO circumcision.
·We will give our son his first bath.
·We would like to remain rooming with our son at all times and to go home as soon as possible with our son. We are aware that extremely competent home health care nurses are available and would welcome the opportunity to use them if necessary.
