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5,727 Posts
Discussion Starter · #1 ·
Anyone else working on or planning to do a birth plan/intention/goal list?

Should we share our works in progress? Would that be helpful?

I've got mine mostly finished -- a few points I need to clarify with my midwife and the ped, but the main gist is there. I think. I'm sure I'm forgetting something though....

And I know people say the longer it is, the more likely it will fall flat, but a lot of it depends on your primary caregiver, and the place you're birthing. The women's center we're going to is very good about following birth plans. You have to be very, very specific though, and last time I wasn't.

Anyway, I thought I'd see how others here felt about the notion of sharing our plans -- or if there even were others here writing birth plans (since we have a lot of homebirthers in our midst).

2,924 Posts
Here's mine from my last hospital birth. I had a great midwife, so most of this was a formality, and just a "getting to know you better" kind of thing. But, also, it was to keep the rest of the hospital staff out of our hair. We also talked to the peds office ahead of time and had it included in my chart that we were rejecting the vit K, eye drops, and hep B on religious grounds. It worked wonderfully. Anytime it was brought up, we restated that we were religiously opposed and referred the staff to the chart with the note made by the head Ped, and it was a done deal. They would just shrug and walk out. It was obvious they were talking about us a lot at the desk though...when they were trying to get a heel stick for the metabolic testing (which we opted to allow afterall) the nurse (who was new on duty) couldn't get him to bleed because he kept clotting so fast. She said, "Huh, I guess he didn't need the vitamin K...." We laughed quite a bit about that later. Anyway, I was very thankful for doing the thing with the peds office ahead of time. The midwife was only there for the birth and just after...then she went home and we were on our own from there. Without that, I can see how we could have had a frustrating time.

So, here's my birth plan. In retrospect, I would have phrased it more positively than we did here.

I trust that my practitioner will seek out my opinion concerning all of the issues directly affecting my birth before deviating from my plan.

I would like to have no time restrictions on the length of my pregnancy. If I go past my due date and the baby and I are fine, I prefer to go into labor naturally rather than be induced. If induction becomes necessary, I would like to try natural induction techniques first.

I would like to discuss laboring at home as long as possible. If I am less than 5cm dilated, even if my water has broken, I would like the option of returning home. If my water breaks before I go into labor, I would like to have no time limits and rather talk about alternative treatments.

I prefer to have no vaginal exams until I go into labor. During a vaginal exam, I prefer at no time to have my membranes stripped or broken. I would like no internal vaginal exams during my labor until I have an urge to push.

Upon arrival at the hospital, I prefer to have my husband with me at all times. I prefer to give birth in a room with a shower. I would like the option to use a birthing ball, squatting bar, and to be able to walk around and move as I wish during labor, and to labor in whatever position or location feels right at the time, to include the shower, on the toilet, hands and knees, squatting on a birthing ball, standing or laying. I do not want to be touched, with the exception of a medical emergency, during a contraction. I do not want to be touched without my consent.

I would like for people entering the room to speak softly, and to use natural light if possible, but not necessarily exclusively.

I would like to have no restrictions on food or fluids during my labor. I prefer to have no IV, but will accept a heparin or saline lock.

Please offer pain medications ONLY if I ask for them. After medical guidance for pain relief, I would appreciate some private time with my husband to discuss which pain management technique I would like to use.

I prefer the baby be monitored intermittently using a Doppler or fetoscope.

As long as the baby and I are healthy, I prefer no time limits on pushing. I would like to have the option to birth in whatever position seems right at the time, to include: squatting, classic semi-recline, and hands and knees. No stirrups please, unless there is an emergency. It's important to me to push instinctively. I do not want to be told how or when to push.

I will ask for an enema or a catheter if I feel that I need one.

I prefer to risk tearing over an episiotomy, unless there is an emergency. If I need an episiotomy, I prefer a pressure episiotomy if possible. Please use a local anesthetic for repairs with ample time for the anesthetic to take effect. I do not want local anesthetic during birth without consent.

I would like for my husband to catch the baby. I would like for my husband to cut the umbilical cord.

I would prefer for the placenta to be born spontaneously without the use of pitocin, and/or manual extraction.

As long as my baby is healthy, I would like my baby placed immediately on my abdomen following the birth. Please do not separate me and my baby until after my baby has successfully breastfed on both breasts. Please delay all essential routine procedures on my baby until after the bonding and breastfeeding period. If the baby has any problems, I would like my husband to be present with the baby at all times.

We would like to give our baby the first bath. Please direct us in the process at the hospital.

I would like no administration of eye drops to my baby. (we included the state law here, and stated that we would have objection papers with us)

Please do not administer vitamin K to my baby. (we put the state law and the bit about the objection papers here, too)

We decline routine PKU testing at the hospital and have made other arrangements for this procedure at a later date.

Do not vaccinate my baby.

Do not circumcise my baby.

My baby is to be exclusively breastfed. Do not offer my baby anything without my consent, to include formula, pacifiers, any artificial nipples, or sugar water.

I prefer full-rooming in, no separation, no exceptions, unless my baby is sick. If my baby does leave my room, it is to be accompanied by my husband or me.

I prefer a private room and to have my husband and daughter stay with me for the duration of my hospital stay. I would like my guests to be permitted to stay as long as they wish.

I prefer to have my hospital stay as short as it can be, but no less time than the stay of my baby.

2,055 Posts
I think it is a great idea. I'm almost finished with mine and will post tomorrow. I'd like to see others for ideas I haven't thought of or have forgotten. I may change it a bit after our hospital tour next week also. I have a few questions about normal protocol I'd like to ask before I show it to my OB...I'm figuring if they normally do it, I don't need to include it in my plan. We'll see.

498 Posts
I'm doing a hospital birth and they gave me a birth plan checklist. I see a nurse practioner so she won't be able to deliver my baby and I won't be able to meet the doctors/residents who may deliver my baby. But she did recommend laboring at home for as long as possible. I live super close to the hospital - it takes us literally 3-4 minutes to get there.

I checked that I wanted dim and quiet environment, no epidural, to meet the ped. on duty, to be able to birth in any position I deem comfortable, skin to skin contact immediately after baby, to delay newborn procedures so I can bond/feed my baby, to have all medical procedures explained to me beforehand, my husband is to accompany the baby if they take the baby away from me for any procedures, that I will breastfeed only and would like a lactation consultant, to consult me before anything is done to my baby and that we are not circumsizing our baby.

I know several people who have birthed at my hospital but they were more, whatever it takes to get the baby out. So I am anxiously waiting for the birth story of another mama in the Dec DDC who will be birthing at my hospital to find out her experience!

6,192 Posts
Here is the one I just wrote this weekend for Amelia's birth. Obviously the ones I had for my 2 vaginal births were a little more detailed...but this time around, our goal is to "get baby out, get her breathing & nursing, and get mama and baby home healthy". Obviously, with my medical condition, Mia being a preemie, and her heart issues, our birth plan had to be very flexible and allow for medical interventions to be a little more freely used than a typical normal healthy full term birth. But I am still hoping that they will be able to follow at least most of it... I'll be going over it with my peri on Tuesday.

Type of birth: Planned c-section Pediatrician: XXXXXX

Dear Dr. XXXXXXX and the Staff at XXXXXXXXXXX,
We are looking forward to sharing in the birth of our daughter, Amelia Rylie, with you. In 2005, we experienced the loss of our son, Ryland, during birth. As a result, Allison is still recovering from the effects of Post Traumatic Stress Disorder. In order to help minimize anxiety and to help create a more relaxing and positive experience, we have discussed our preferences for the birth of our baby. We fully realize that situations may arise such that our plan cannot and should not be followed. However, we hope that barring any extenuating circumstances, you will be able to keep us informed and aware of our options. Thank you.

Medical information:
-Allison has Essential Thrombocytosis, or excessive platelets
-Allison has a severe allergy to Penicillin. She also has extreme sensitivities to Reglan, Pheneragan, Xanax,

-Please allow David XXXXXXX (Allison's husband) in the operating room. Allison's doula, XXXXXXX XXXXXXXXX should be present at all other times (during pre-surgery and recovery as allowed) to assist with anxiety or emotional issues. Please allow her to be scrubbed up and ready to go in the operating room if David must leave for any reason.

-Please refer to the c-section as a birth rather than a surgery in the operating room

-Allison has had extreme negative reactions to anxiety medications in the past. Please avoid using them unless medically necessary.

-At all times, please keep Allison informed of her and the baby's status, both positive and negative.

-Please allow soft relaxing music, or Allison to listen to music on an iPod, during the birth.

-Please inform us when photography is allowed.

-Please hold the baby up immediately after birth so Allison can see her.

-If the baby's Apgar scores are good, please allow Allison to breastfeed and touch the baby in the operating room prior to the baby being taken to the nursery.

-When the baby is taken out of the operating room to the nursery, please allow David to go with the baby, and the doula to enter the operating room.

If the baby is in the Regular Nursery immediately post-birth:
-Please allow David to accompany the baby to the nursery at all times, as long as the baby's health allows.

-Please bring the baby to Allison as soon as the 4 hour required observation is up to begin breastfeeding, if the baby's health allows.

-If the baby is not well enough to leave the nursery after the observation period, please assist Allison in going to the nursery to see and/or breastfeed the baby.

If the baby is in the NICU:
-Please assist us in pumping breast milk as needed for the baby, and obtaining a prescription for human milk from the Ohio Milk Bank if enough breast milk can't be pumped.

-Please take pictures of the baby with a disposable camera we provide during times we aren't allowed to be with her.

-Please assist us in beginning kangaroo care as soon as possible.

General baby care:
-We would like to begin kangaroo care as soon as possible.

-If the baby's health allows, we would like to room in 24 hours a day after the initial postpartum observation period.

-We will be breastfeeding, and using a Supplemental Nursing System as necessary due to Allison's history of low supply. Please do not use bottles unless the baby's health requires it.

-The baby's older brother had severe vaccine reactions and is autistic. Please do NOT administer any vaccinations in the hospital, including Hepatitis B. Our pediatrician will administer them at a later date (The PKU test, the eye drops, and the Vitamin K injection are all ok).

-We have a 5 year old son (Brandon) and a 23 month old daughter (Jocelyn) who will be visiting the hospital during our stay.

5,727 Posts
Discussion Starter · #7 ·
Okay, I've edited it some, and broke it into sections, based on my doula's recommendations.

Hopefully this will make it less overwhelming. Still need to ask the ped about some stuff and get my midwife's input, but so far it's getting smaller. Which is good.

Labor Preferences for Renée XXXX

Present during labor and at the birth: XXXX (father), XXXX(midwife), and XXXX (doula).

No students or unnecessary staff present during the labor or delivery, please.

We are attempting to have a natural, non-medicated birth. The mother has been diligently practicing labor and birth hypnosis for this reason.

The environment is important to us. We ask that lights be kept dim, noise be kept to an absolute minimum, and the door be kept closed for privacy.

Please do not offer any forms of medicinal/chemical pain relief. If any should be required, we will ask for them.

The mother prefers a heparin/saline lock. She will maintain hydration orally, and no medications are to be administered intravenously without her informed consent.

The mother prefers not to have a catheter unless following the administration of an epidural (which she will request if needed).

She may wish to wear her own clothing and would like the opportunity to be out of bed as much as possible during labor, depending on her needs.

We request that any monitoring of contractions be done via the cordless monitor externally, or be done intermittently, externally.

We request that only the midwife (XXXX) perform cervical checks during labor.

Should labor become stalled, we request non-invasive procedures be offered/allowed. No PROM nor pitocin unless dire circumstances arise.

Prior to any medical intervention being introduced, we request that the parents be made fully aware of the purpose, potential side effects, and any alternatives.

We request that we be allowed some time to discuss any potential intervention with our doula or midwife.

Birth Preferences for Renée XXXX

The mother would like to push at her own pace. Please do not count during the pushing stage.
She requests that warm compresses be used to help prevent tearing.
The mother requests being directed to pant through in order to slow pushing should a tear threaten.
No episiotomy.
The mother would like to be able to change position for delivery as needed, should the pushing stage become stalled.
Please allow the cord to stop pulsing before cutting.
(Insert thing here about cord blood banking?)
Please offer the father the opportunity to cut the cord.
Please do not pull on cord to help release placenta.

Post-Delivery Preferences for Renée XXXX
The baby is to be placed on mother's chest immediately following delivery, for skin-to-skin contact and bonding.

It is not necessary for staff to clean baby during this time.

The baby is to remain with the mother for at least one full hour (or longer) after birth, for bonding and to establish breastfeeding on both sides.

Baby's Apgar scores can be assessed on mother's chest.

Please do not bathe baby. The parents wish to do this themselves.

We respectfully refuse the Hepatitis B vaccine at this time. Our pediatrician is aware of this decision (see signed waiver) and our intention to delay vaccination for our baby, who is not high risk for the disease this vaccine treats.

We respectfully refuse neonatal ocular prophylaxis, as the mother has tested negative for the two diseases (gonorrhea and chlamydia) whose symptoms it treats. Our pediatrician and midwife are aware of this decision (see signed waiver) and our legitimate reasons for it. We believe the overuse and abuse of unnecessary antibiotics is irresponsible and detrimental to the health of our child.

We respectfully request the Vitamin K shot be delayed until after breastfeeding has been established and mother and baby have had an initial opportunity to bond.

We would like to be made aware before the shot is to be administered so that the mother can breastfeed baby during the procedure.

Please inform the mother or father prior to newborn's PKU test being performed, so that the mother may breastfeed during procedure.

Absolutely no medication is to be given to our baby without the parents' prior informed consent.

While all indications are that this baby is female, should baby in fact be male, we refuse the circumcision procedure.

We would like to have a set of footprints for our baby album if possible.

Should it be necessary for baby to be warmed, we request mother be allowed to place baby skin-to-skin, with heated blankets covering both, rather than heating lamps be used.

Should it be necessary for baby to be taken to the nursery for any reason, please ensure she is returned to mother at least every two hours for nursing. Sooner should baby be distressed.

Please do not offer baby any bottles or pacifiers as mother intends to exclusively breastfeed.

We prefer to room in with baby and request nighttime checks on mother and/or child be kept to a minimum if possible.

We would like to meet with a lactation consultant if possible.

We would like to be allowed to return home with our child as soon as possible (following the PKU test/delivery???), for the health and well-being of both mother and baby. Our pediatrician and midwife are aware of this intention.

Thank you for helping us make this experience as ideal as possible for both the mother and father, and especially for our newborn baby. We appreciate your support, encouragement, and willingness to respect our wishes as we bring our newest family member into the world.

-Renée and XXXX XXXX

In the Case of Emergency Procedures for Renée XXXX

We understand that there are procedures that may become necessary under dire circumstances.

We ask that we be given the opportunity to accept or refuse any procedure or medication, and make an informed decision regarding all procedures or medications beforehand. Should the mother be unable to do this, the father is to be allowed to do so in her stead.

We request that the least invasive or restricting versions of procedures be used.

Under no circumstances, barring potential death of or permanent damage to fetus or mother, should a C-section be performed. Should a C-section become necessary, then we request the mother be given an epidural rather than general anesthesia, the father be in the delivery room.

Please do not restrict mother's arms or hands, and we request that the baby be given to the mother immediately following delivery for bonding and to establish breastfeeding.

It is not necessary for baby to be cleaned prior to bonding with mother. We prefer baby to not be bathed, as we would like to do this ourselves.

We request both father and baby remain in the recovery room with mother after the procedure.

Should the baby require medical attention separate from the mother, the father is to remain with the baby at all times, and we request that either the midwife or doula remain with the mother.

Please do not give prophylactic antibiotics nor other medication to mother or baby without informed consent from mother (or father) beforehand.

Please see "Post-Delivery Preferences" for information regarding which medications and procedures are acceptable for our newborn.

Thank you, Renée and XXXX XXXX

2,055 Posts
This is what I've put together. I'm still not sure where/how to explain the hypnobabies we are using. I may end up tweaking a bit...

The XXXX Family Birth Preferences
We are looking forward to sharing our upcoming birth with you. We have created the following birth plan to help you understand our preferences for our upcoming labor and delivery. We fully understand that in some circumstance these guidelines may not be followed but it is our hope that you will assist us in making this the experience we hope for. Thank you in advance for your support and encouragement during our birth.
Sue and Brian XXXX

First Stage (Labor):
•Sue's mother will be present at the birth but we prefer no other visitors unless cleared by us.
•Please do not offer me medications, I will ask for them if I decide that I want them.
•I would like to use the bathtub during labor.
•I would prefer to move around and change positions at will.
•I prefer to eat and drink to my comfort level.

Room Environment:
•We will be using various forms of self-hypnosis throughout labor and delivery.
•We would prefer dim lights in the room and low voices to be used.
•Please avoid references to "pain", "hurting" or "hard work" as these words are disruptive to our hypnosis process. Referring to comfort level is more appropriate.

•I would prefer to use natural methods to start or augment labor.

Second Stage (Birth):
•I would like to use the position of my choice for birth.
•Even if I am fully dilated, and assuming my baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.
•I would prefer to tear than have an episiotomy, but please use compresses, massage, and positioning.
•I would like to have my baby placed on my stomach/chest for skin-to-skin contact immediately after delivery.

Baby Care:
•Please delay all routine exams for longer bonding time; all routine exams to be done in room with mom.
•We will be exclusively breastfeeding; no pacifiers or glucose water.
•We prefer no separation of mother and baby, my husband will accompany the baby if separation is necessary
•No eye medication or HepB vaccine.
•Please do not bath our baby, as we prefer to do this ourselves.
•Although we are expecting a girl, if our baby is a boy, we will decline circumcision.

•Early discharge, if mom and baby are well.

5,727 Posts
Discussion Starter · #11 ·
I think the way you worded the hypnosis is fine, honestly.

And I'm amazed at how succinct yours is, compared to my tome. I definitely need to work on whittling mine down. Thankfully the doula's coming this week and hopefully she can help.

178 Posts
Aye! I know this is long and detailed and it should be short and sweet. We are homebirthing and most of this applies to a hospital transfer. I tried to leave out explanations of what we hope to do, and including only requests about what we would like them to do/not to do. I didn't want to phrase it as "we would prefer" or "if possible" as I'm afraid that comes across as if "we'd like this if you can get to it or don't mind."

Birth Plans for our Home Birth (for our midwives)
(Note that this is not as detailed because there are many things that are already understood with our midwives - it is only in the event of a hospital transfer that we are more concerned.)

-Ejg might want to labor in a birthing tub, or not. She typically is not a fan of water, but sometimes warm baths or showers help to relax her. She probably will not birth in the tub so that her perineum can be supported to prevent tearing.
-Ejg would like to avoid internal exams if possible, but this is open to discussion of course. After membranes have ruptured internal exams please only if absolutely needed.
-E's partner would like to catch the new little one if possible. Ejg and E's partner will see for themselves if it is a boy or a girl.
-Ejg would like to hold and nurse the baby as soon as possible after the birth.
-We would like to wait until after the placenta is birthed and the cord has stopped pulsing to cut the umbilical cord.
-Ejg would prefer not to have an episiotomy unless required for the baby's safety.
-Ejg would like to nurse as soon as possible and welcomes suggestions about positioning, etc. She has read about it, but reading is so different than doing!
-We are open to a hospital transfer in order to protect the well-being of Ejg or the baby, but would like to avoid this unless it is a matter of safety. Assuming that XXXX Hospital (17 minutes away) is equipped for our needs (i.e. if there may be a need for a rapid c-section), we would like to transfer there. In the event that we need a better equipped hospital (and there is time), XXXXXX Hospital (30 minutes away) is second choice.

In the Event of a Hospital Transfer

Labor and Birth
-Internal exams: decline unless essential. If the membranes have ruptured, please no internal exams unless the health of Ejg or the baby is absolutely dependent on this.
-Midwife: We would like our midwife with us at all times
-Mobility: free to walk around during labor, and position herself as she likes during birth.
-Enema and/or shaving of pubic hair: Decline.
-Food/water: Ejg needs to be able to eat and drink as she likes.
-Noise: As quiet as possible. Ejg is an introvert and prefers to avoid conversation during labor and birth.
-Lights: low
-IV: Decline unless dehydrated.
-Pain meds: Decline. Will request if desired. Please do not ask.
-Continuous fetal monitoring: Decline unless it is discussed and absolutely necessitated by dangerous circumstances. Please discuss with Ejg and partner first.
-Internal monitoring: Decline unless the baby has shown some sign of distress and a monitor is discussed and deemed essential.
-Labor augmentation meds: Decline unless there is a clear, imminent risk to continuing to labor without augmentation. At that point, Ejg and E's partner would appreciate discussing it with the care provider.
-Artificial Membrane stripping or rupture: Decline unless clear signs of fetal distress require this. At this point, Ejg would like to discuss with the provider.
-Episiotomy: decline unless absolutely required for Ejg's or baby's safety
-Please support the perineum with warm compresses during birth to help reduce risk of tearing.
-Please do not coach/encourage pushing unless there is a risk to Ejg or baby.
-Please no non-essential personnel be present during labor or the birth.

After Baby Is Born
-Holding baby: Ejg needs to hold the baby as soon as he or she is born and wishes any procedures or assessments to be done while baby is on her chest or abdomen.
- Procedures and assessments: Ideally the baby will stay with Ejg at all times after birth. If the baby MUST be taken away for essential medical procedures E's partner needs to be with the baby at all times. If baby needs to be warmed, please use heated blankets while he/she is on Ejg's chest.
-Delay of procedures: Unless the baby's health is at risk, please delay any assessments that cannot be done on Ejg's chest, or procedures until Ejg, E's partner and baby have had time to nurse, rest and bond.
-Bathing: Ejg and E's partner would like to bathe the baby after bonding and resting.
-Breastfeeding: Ejg plans to breastfeed the baby and would like to begin nursing very shortly after birth to aid in expelling the placenta.
-Cord pulling/clamping/cutting: Please do not pull on the cord. Please do not clamp the cord until it has stopped pulsing and the placenta has been delivered, unless not clamping and cutting cord is endangering the health of the baby or Ejg.
- Please do not perform any procedures on Ejg or baby, or administer any medications, without Ejg or E's partner's clear, informed permission.
- Hep B shot, eye ointment, vit. K, circumcision, and retraction of foreskin: Decline. See attached religious exemption.
-Pitocin after the delivery to aid in expelling the placenta: Decline
-Bottles: Decline all, including glucose water or plain water.
-Pacifiers: Decline
-Catheterized: Decline until Ejg has some private time to see if she can urinate on her own.

In the Event of a Cesarean
- Cesarean: Decline unless ABSOLUTELY necessary to protect the health of Ejg or baby.
-Ejg needs E's partner to be present in the event of a cesarean.
-Anesthesia: Ejg would like to remain conscious if at all possible.
-Something about the incision and suturing, keeping in mind future VBAC
-Viewing of birth: Screen lowered before delivery of the baby.
-Holding baby: If conditions permit, Ejg would like to be the first to hold the baby after the delivery. If she cannot, E's partner will hold the baby.
- Delay of procedures: Unless the baby's health is at risk, please delay any assessment or procedures that cannot be done while baby is in arms of a parent.
-Please do not separate baby from Ejg or partner unless health/life of baby is at risk. In the event of a separation, W's partner will accompany baby and Ejg's midwife will stay with her.
-If there is an emergency with Ejg, her partner will stay with her and she requests that midwife accompany baby.
-Breastfeeding: Ejg would like to breastfeed as soon as possible after birth.

Thank you so much for considering our needs during this wonderful time as our family grows.

258 Posts
What a great idea!! Mine is fairly long, I'm wordy like that lol. I did try to make it more readable by summarizing each section with a one or two sentence introduction, and bolding the most important points (although I don't think this showed up since I copy/pasted it here), so that even if they don't read it all thoroughly they still catch the most important things. I also feel like my doula will be an excellent advocate for me, and I trust my midwives, so I feel much more relaxed knowing that while the birth plan is good to have and can guide the nurses, my midwife and doula will be guiding things along. This is just for vaginal birth. I am typing a separate one in case of Cesarean. Here goes:

This is a general outline of my wishes regarding my upcoming labor and birth at ____ Hospital. I am looking forward to the birth of my first child, and to working with my care providers and hospital staff to create a positive and empowering birth experience. Obviously in an emergency or unexpected situation, there may be a need for procedures that would not otherwise be my ideal, and I understand that childbirth cannot be easily planned or predicted. The most important thing to me is that I can play an active role in the process and be treated with respect, and given the opportunity to discuss my options if and when the unexpected should arise. Thank you for your support! J

Stage 1/Labor:
I am planning a natural birth and will be using relaxation methods to cope with labor.
*I prefer a calm, low-key environment in my birthing room- dim lights, quiet voices, privacy, and the absence of unnecessary observers.
*I prefer that pain medications not be offered. I will ask if I choose to use them, but am anticipating the use of non-drug strategies only.
*I would like the freedom to move around and to utilize different positions and tools such as a warm bath, birthing ball, etc. if desired.
*I would like to eat and drink as needed to stay hydrated and keep up my energy.

I prefer a minimum of interventions as long as my baby and I are healthy and not in any danger.
*I prefer the use of a Doppler or fetoscope if and when needed rather than continuous external or internal monitoring.
*I do not wish to have time limits placed on my labor if we are healthy and stable.
*I would like to avoid the use of pitocin or the stripping or artificial rupture of membranes and will try natural methods first if needed.
*I wish to avoid cervical/internal exams until the point where I feel the urge to push, or if there is a pressing medical reason to do so sooner. I would like this to be performed only by my midwife.

Stage 2/Pushing:
It is important to me to listen to my body and push instinctively to birth my baby.
*I would like the same calm, peaceful, and private environment described above to be maintained during the second stage.
*I will plan to give birth on the position that feels most natural at the time.
*I prefer to avoid any counting, coaching, or directed pushing please.
*Please assist me by providing lubrication and warm compresses on the perineum as the baby crowns. I do not wish to have a routine episiotomy and prefer instead to use these techniques as well as effective positioning to minimize or prevent tearing.

Immediate postpartum period:
My priority is bonding with my baby and establishing breastfeeding in the period immediately following birth. I prefer that routine procedures be delayed until this has occurred, and wish to avoid any separation from my baby at that time.
*Please place the baby immediately on my abdomen/chest. I prefer all evaluations (APGAR, measurements, etc.) be performed while the baby is on my chest or postponed until later.
*You do not need to clean or bathe the baby right away- I would like to give him/her their first bath and request assistance to do this later after we have had time to bond and breastfeed.

These are my wishes should a special situation arise:
*If the baby needs warming, I prefer skin-to-skin contact with heated blankets placed over both myself and my baby, rather than the use of a warming lamp or other device.
*If the baby needs resuscitation or other emergency procedures, I would like them performed within my sight and to be told what is happening.
*If the baby needs to be separated from me in case of an emergency situation, I would like my doula ____ to accompany the baby to the nursery or other destination. Please see special instructions in case of necessary separation. I consent to have ____ be my representative until I am able to be present, as we have discussed my wishes and preferences at length.

I would like to birth the placenta with minimal intervention and delay the cutting of the cord.
*Please do not cut the cord. I would like to do this myself, after the placenta is birthed and the cord is no longer pulsing. I will let you know when I am ready to do so.
*Please do not pull on the cord or attempt manual or pharmaceutical interventions to facilitate the birth of the placenta. I prefer to use breastfeeding and gentle abdominal massage to encourage the uterus to contract and the afterbirth to detach on its own.

I am declining many of the routine medications, tests, and procedures, and choosing to delay others. I have educated myself about the implications of both accepting and declining various treatments and feel confident in these choices.
*I prefer the heel stick/newborn screening test be delayed until after the first hour, and performed while the baby is nursing to minimize stress.
*I am declining the Hepatitis B vaccine for my child at this time. I have discussed this with the baby's pediatrician.
*I am declining the eye prophylaxis for my child. I have tested negative for the sexually transmitted infections which this treatment would address.
*I am declining the vitamin K injection. However, I would like to have an alternative oral form of vitamin K administered to my baby for the same purpose.
*If the baby is a boy, I choose to decline circumcision.

Let me know if you guys have any input or suggestions!
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