Here's mine. Hope it is helpful.
BIRTH PLAN FOR:
EDD:
In our desire to have the most memorable and happiest birth possible, we have listed our preferences below. These decisions have been made after much research and thought. You can be assured that in the unlikely event of complications, our full cooperation will be rendered after an informed discussion with our doctor has taken place and adequate time for private consideration has been given to us.
INDUCTION/AUGMENTATION
•I would prefer to allow labor to begin spontaneously and without augmentation once it has started.
•No AROM. If medically necessary, I would prefer that it not be performed until I am greater than 4 cm. dilated. If baby is posterior, no AROM until baby has rotated to anterior.
•No induction by means of Pitocin or any other synthetic hormone. If Pitocin becomes medically necessary, I would like the lowest dosage possible and do not want it increased at routine intervals. I would also prefer to have it turned off once labor is established.
•I do not want any gels applied to my cervix and do not consent at any time to use of Cytotec.
MONITORING AND EXAMS
•Intermittent fetal monitoring only. In the event that CFM is necessary, I would like the use of a portable telemetry monitor so that I may remain mobile. No internal fetal monitoring unless absolutely medically necessary.
•Vaginal exams to be kept to a bare minimum especially once my membranes have ruptured.
•Heparin or saline lock only. I would like to be allowed to drink fluids while I labor.
LABOR AND PAIN MANAGEMENT
•I would like to be allowed to move freely during labor (walk, rock, use birthing ball, etc.) and assume whatever position I feel most comfortable.
•I would like dim lights and voices kept low at all times.
•No time limits be placed on labor so long as Mom and baby are doing well.
•No non-essential hospital staff in my room at any time during labor and delivery and do not consent to being treated by any medical students or residents.
•I will be having my husband and a doula assist me during labor with pain management. Please do not ask if I want pain medication. I will request it if needed.
•If I elect to receive an epidural, my goal is to wait until I am at least 5 cm. dilated and the baby's head is engaged in the pelvis. I would like support and understanding in trying to reach this goal.
•I would like access to a shower or tub for pain management.
DELIVERY
•Please no time limits imposed so long as Mom and baby are doing well.
•I would like to assume different birthing positions if I am physically able (on hands and knees, squatting, side-lying). Please no flat-back pushing.
•Mother directed instinctive pushing rather than coach-directed. Please no counting.
•No episiotomy. If I am to suffer a small tear (1st or 2nd degree), I would prefer to tear rather than be cut. I request that warm compresses [and counter pressure] be applied to my perineum at the time of crowning to minimize tearing.
•If I elect to receive an epidural, I would like it turned down during delivery so that I can feel the urge to push.
•I would like to use of a mirror so I may watch the delivery.
•I do not want a uterine examination after birth unless medically indicated (excessive blood loss, HBP, fever).
•I would like to deliver the placenta naturally allowing the full 5 or 10 minutes for expulsion without any medication or physical assistance, specifically no pulling or holding taught on the umbilical cord. I do not want a routine injection of Pitocin after the delivery to aid in expelling the placenta.
•I would like the baby to be placed on my abdomen or chest (cord permitting) immediately after birth and cleaned and suctioned while I hold him or her.
BABY
•All procedures on our baby should be done where my husband and I can see and if necessary to remove the baby from the room, I would like my husband to be present. I will be exclusively breastfeeding. Please no supplementary bottles or pacifiers without my consent.
IF A CESAREAN BECOMES NECESSARY
•I would like my husband to be present during prep and anesthesia.
•Unless absolutely necessary for the safety of the baby, I want a low transverse incision to be done and preferably along the same scar as my first.
•I would like to screen to be lowered and the baby shown to me before he/she is taken to the warmer to be cleaned.
•Please use a double-layer suture to close the incision on my uterus.
•I would prefer that my arms not be restrained or at least freed after baby is born in order to hold him/her with assistance from my husband.
•I would like the surgeon to note any scar tissue or damage from my previous cesarean.
BIRTH PLAN FOR:
EDD:
In our desire to have the most memorable and happiest birth possible, we have listed our preferences below. These decisions have been made after much research and thought. You can be assured that in the unlikely event of complications, our full cooperation will be rendered after an informed discussion with our doctor has taken place and adequate time for private consideration has been given to us.
INDUCTION/AUGMENTATION
•I would prefer to allow labor to begin spontaneously and without augmentation once it has started.
•No AROM. If medically necessary, I would prefer that it not be performed until I am greater than 4 cm. dilated. If baby is posterior, no AROM until baby has rotated to anterior.
•No induction by means of Pitocin or any other synthetic hormone. If Pitocin becomes medically necessary, I would like the lowest dosage possible and do not want it increased at routine intervals. I would also prefer to have it turned off once labor is established.
•I do not want any gels applied to my cervix and do not consent at any time to use of Cytotec.
MONITORING AND EXAMS
•Intermittent fetal monitoring only. In the event that CFM is necessary, I would like the use of a portable telemetry monitor so that I may remain mobile. No internal fetal monitoring unless absolutely medically necessary.
•Vaginal exams to be kept to a bare minimum especially once my membranes have ruptured.
•Heparin or saline lock only. I would like to be allowed to drink fluids while I labor.
LABOR AND PAIN MANAGEMENT
•I would like to be allowed to move freely during labor (walk, rock, use birthing ball, etc.) and assume whatever position I feel most comfortable.
•I would like dim lights and voices kept low at all times.
•No time limits be placed on labor so long as Mom and baby are doing well.
•No non-essential hospital staff in my room at any time during labor and delivery and do not consent to being treated by any medical students or residents.
•I will be having my husband and a doula assist me during labor with pain management. Please do not ask if I want pain medication. I will request it if needed.
•If I elect to receive an epidural, my goal is to wait until I am at least 5 cm. dilated and the baby's head is engaged in the pelvis. I would like support and understanding in trying to reach this goal.
•I would like access to a shower or tub for pain management.
DELIVERY
•Please no time limits imposed so long as Mom and baby are doing well.
•I would like to assume different birthing positions if I am physically able (on hands and knees, squatting, side-lying). Please no flat-back pushing.
•Mother directed instinctive pushing rather than coach-directed. Please no counting.
•No episiotomy. If I am to suffer a small tear (1st or 2nd degree), I would prefer to tear rather than be cut. I request that warm compresses [and counter pressure] be applied to my perineum at the time of crowning to minimize tearing.
•If I elect to receive an epidural, I would like it turned down during delivery so that I can feel the urge to push.
•I would like to use of a mirror so I may watch the delivery.
•I do not want a uterine examination after birth unless medically indicated (excessive blood loss, HBP, fever).
•I would like to deliver the placenta naturally allowing the full 5 or 10 minutes for expulsion without any medication or physical assistance, specifically no pulling or holding taught on the umbilical cord. I do not want a routine injection of Pitocin after the delivery to aid in expelling the placenta.
•I would like the baby to be placed on my abdomen or chest (cord permitting) immediately after birth and cleaned and suctioned while I hold him or her.
BABY
•All procedures on our baby should be done where my husband and I can see and if necessary to remove the baby from the room, I would like my husband to be present. I will be exclusively breastfeeding. Please no supplementary bottles or pacifiers without my consent.
IF A CESAREAN BECOMES NECESSARY
•I would like my husband to be present during prep and anesthesia.
•Unless absolutely necessary for the safety of the baby, I want a low transverse incision to be done and preferably along the same scar as my first.
•I would like to screen to be lowered and the baby shown to me before he/she is taken to the warmer to be cleaned.
•Please use a double-layer suture to close the incision on my uterus.
•I would prefer that my arms not be restrained or at least freed after baby is born in order to hold him/her with assistance from my husband.
•I would like the surgeon to note any scar tissue or damage from my previous cesarean.
