PARENTS: Benjamin and Jodi XX
MW's Emergency Phone Number: XX
Ped's Emergency Phone Number: XX
MOTHER'S ALLERGIES: Emycin & Sulfa
I have attached a copy of my medical history.
My husband and I are wanting to express our wishes for the birth of our fifth child.
I would like our wishes regarding this birth to be followed, barring any extenuating circumstances.
Should a emergency/problem arise, I want to be informed of any procedures beforehand.
I wish to let labor naturally, without augmentation.
I want to be as mobile as possible, choosing my own positions.
I will more than likely wish to labor in the tub once active labor has started.
I prefer only my husband, our doula, and my mother to be present during labor/delivery.
No other guests without my approval.... and I would greatly appreciate minimal staff or interruptions.
After the initial strip, we prefer monitoring to be done occasionally via fetoscope or doppler.
I am GBS+, and aware that a bag of antibiotics have to be ran into my system.
Once the antibiotics have been administered, I prefer the IV removed completely, or if absolutely necessary, a heparin lock left in.
NO Medication is to be given to me via IV, unless first discussed with my husband and I.
I prefer internal exams to be kept at a minimum.
Preferably upon my request only.
I am GBS+, and don't wish to risk undue infection to my child, or myself.
I wish to labor naturally, with no medication.
Please do NOT offer me any type of pain medication.
If I want it, I will have my doula or my husband request it.
*Artificial Rupture of Amniotic Membrane:
I prefer my birth to progress naturally, and do not want my amniotic membrane ruptured.
I would like to push in a position of my choosing... preferably one that will allow gravity to help.
NO routine episitomy, I prefer to tear if necessary.
In the event of a tear, please wait until after the placenta has been delivered, before giving me a local and stitching the tear.
NO oxytocin/pitocin injections unless absolutely necessary, and ONLY with my permission.
ONCE BABY HAS ARRIVED
Baby is to be placed immediately on my chest or stomach.
Delay the clamping and cutting of umbilical cord until it has stopped pulsing.
My husband or I will cut baby's cord.
*Screening, Testing, Vitals:
Prolonged skin to skin contact with mother and baby.
Please refrain from any tests, weighing, etc.. until we have had at least 30 minutes or longer to get to bond.
Baby is to receive NO Eyedrops/Ointments *we will sign a waiver if need be*
NO vitamin K, either orally or by injection.
*We will sign a waiver if needed.*
No hepatitis B injections.
*We will sign a waiver if needed*
No PKU testing... Baby's pediatrician will do that at baby's 1 week check-up.
*We will sign a waiver if needed.*
*Feedings, Separation, etc..
I plan on breastfeeding, should baby need formula, my husband will feed him via syringe. (No artificial nipples please)
I feel very strongly about not being separated from my baby at any point.
I prefer that any and all tests be preformed while I am with him.
In the event that I am indisposed, my husband or one of my family will accompany baby at all times.
My husband or I will give baby his first bath, please do not attempt to remove the vernix from his skin.*Circumcision:
Please do not circumcise baby, as I do not want my sons genitals mutilated.
Should a caesarean section become necessary, I would prefer epidural anesthetic.
I would like my husband present
Baby to be placed on my chest immediately after birth.
*Problems with my health:
If I am unable to care for my baby, I would like my husband (or other family member) to care for him.
I prefer that the baby receive only my breast milk.
*Problems with baby's health:
I would like unlimited visitation for my husband and I.
I would like to be able to touch and breastfeed the baby as soon after birth as possible.
Should baby need to be transported/transferred, please release me immediately, so I can be with him.
So, whatcha think?
Did I forget anything?
Should I remove something?