Sample Birth Plan

by | Jun 6, 2015 | Uncategorized | 0 comments

Below is an example of a sample birth plan. Use it to expand your research and adapt it to suit your birth desires!

123

Dear Prospective Doctor,

I have taken the time to type up a list of the things that are important to me for the care of the remainder of my pregnancy (I am currently 30 weeks pregnant) and the delivery of my baby. I realize that I may have views that are different from the standard of care you normally follow and that I may need to be flexible on some of these points.

It is important to me to have a pregnancy and birth with as little intervention as possible however, my child’s well‐being is my priority and all of these requests are negotiable should there be a risk to my baby. Please review my requests carefully and let me know if you are willing to work with me.

Remainder of the pregnancy – these are the issues that I have had the chance to form opinions on, as the pregnancy progresses others will probably come up.

  1. G.T.T. – I do not want to have a routine GTT. I would prefer to have my urine monitored, if glucose spills into my urine I will agree to have one. If you absolutely feel it necessary I am willing to have a 2 hr. post prandial test. (Blood drawn after a lg. Breakfast.)
  2. Sonogram – I had a sonogram at 20 weeks (report will be in my records). I do not want another sonogram unless a complication arises that makes it necessary.
  3. Doppler ‐ The Doppler was used during prenatal visits until the 24th week (6 times). Now that the baby’s heartbeat is strong enough to be heard with a fetoscope, I would like it to be used for the remainder of my prenatal visits. If a problem/complication is suspected by the fetoscope that necessitated the use of the Doppler, I will not object.
  4. Vaginal exams in the third trimester – I do not want any routine vaginal exams. I will agree to have one only if there is a clear risk to the baby that necessitates it.

Labor

  1. Enema – I would like to have the option of whether or not to have one.
  2. Shaving ‐ I do not want to be shaved.
  3. I.V. – I do not want to have an IV. If it is absolutely necessary, I will agree to have a needle in my vein for access in case of an emergency.
  4. Vaginal exams ‐ I do not want routine exams while in labor. I would like to be checked when I arrive at the hospital. After that only when I request to be examined (because I feel I have progressed) to determine if I can begin pushing.
  5. E.F.M. ‐ I feel very strongly that I do not want routing fetal monitoring while in labor. I would prefer to be checked routinely with a fetoscope. Once again, if a problem/complication arises that necessitates the EFM to confirm or decide on course of action, I will not object.
  6. Internal Fetal Monitoring – I do not want to have this done under any circumstances.
  7. Bath/Shower – I would like to be allowed to get in the bath or shower, even if the bag of waters has ruptured.
  8. If I am not vomiting, and want to, I would like to be allowed light food and clear liquids.
  9. I would like the freedom to walk and move around as much as I want during labor.
  1. I would like to be in a sitting, squatting, on all fours or side lying position during the pushing stage of labor. Again, with the freedom to change positions as much as I want to.
  2. I would like to be in a vertical position for the birth.
  3. I want to control pushing with instructions on when not to push only.
  4. I do not want stirrups or any type of restraints to be used.
  5. Episiotomy – I am taking as many steps as possible to avoid the necessity of an episiotomy. I would appreciate perianal support and guidance of the baby’s head to prevent superior tearing. I would prefer to be allowed to tear a small amount with an episiotomy performed only if it is going to be large tear.
  6. Forceps Vacuum Extraction – I feel very strongly that these interventions should be used only in emergencies. I do not want these to be used unless the baby’s life is threatened.
  7. Breaking Stripping the membranes – I would like for the bag of waters to be allowed to break on its own. If my labor stalls for an extended period of time, I would appreciate having this option first discussed with me. If a complication arises that threatens my life or the baby’s life, I realize the bag of waters may have to be artificially broken.
  8. Pain medication – during labor – It is very important to me to have this baby without the use of pain medication. I would appreciate it not being offered. I realize however, because this is my first child and I have not experienced childbirth before, I may find it necessary to have the help of pain medication. For this reason, I would like to discuss my options ahead of time. I would prefer a fast acting / short half‐life general anesthetic to an epidural. If repair work is necessary, I would appreciate a local anesthetic, after the cord has been cut.
  9. Contraction inducing drugs (ie. Pitocin) – I would appreciate every step possible being taken to avoid the necessity of using this drug both before the baby is born and for expelling the placenta.
  10. 3rd stage – Please allow the placenta to be expelled on its own, with no pulling or tugging. I do not want to be given Pitocin. If a complication arises that prevents the natural expelling of the placenta, I would like for my options to be discussed with me.
  11. Cutting the cord – Unless a complication arises that does not allow the time to wait, please do not cut the cord until it has stopped pulsating. Also, please do not milk the cord to speed this process.
  12. C‐Section – Obviously it goes without saying that I do not want a cesarean but, if it becomes necessary to protect either my or my baby’s life, I realize it will have to be done. I would like to request however, that my husband be allowed to be present and he be allowed to escort the baby to the nursery when it is born.
  1. The birth – If there are no complications and the baby appears to be healthy, on the last push. I would like the baby to be immediately handed to me or placed skin to skin on my chest. I would like for any observations or measurements that cannot be delayed to be performed with the baby on my chest.
  2. Suctioning – I do not want the baby’s air passages suctioned automatically if it is attempting to clear them on its own (coughing, sneezing). I would like instruction so I can use the fetal Heimlich maneuver to assist the baby in clearing its air passages.
  3. Breastfeeding – I would like to begin feeding the baby as soon as it is determined to be safe. (ie. air passages are clear). The above represents my birth plan so far. As I have already said, I realize I may have to make changes. Please let me know once you have had the opportunity to look it over. Thank you for your time and consideration.

Sincerely, ___________________________________

 

Care Plan for Baby:

  1. Rooming – in – After the birth, if there are no complications, I would like for rooming in to begin immediately. All necessary examinations will be performed in my room with no separation from the baby
  2. Breastfeeding – The baby will be breastfed exclusively. Unless there is a complication that does not allow breastfeeding (in which case I would like to be allowed to express my colostrum for the baby), we want the baby to begin nursing immediately after birth and on demand thereafter. Please do not give the baby a pacifier, bottled water, glucose water or formula.
  3. Please delay weighing, measuring, footprinting and any other tests/measurements/ observations that can be delayed for at least one hour after birth. We would like for all of these procedures to be done in our room.
  4. Erythromycin ointment is not to be put in the baby’s eyes.
  5. Circumcision – We have decided not to circumcize our baby.
  6. Vitamin K Shot – We do not want the baby to be given this shot.
  7. PKU and other metabolic disorders – We do not want our child to be tested for these disorders until it is 24 hours old. If we have been discharged by then, we will have our pediatrician test the baby on its first visit.
  8. Hepatitis B ‐ We do not want the Hepatitis B Vaccine given to our baby.
  9. No lab work is to be drawn; no injections or medications of any kind are to be given without our prior consent.
  10. I do not want the vernix to be washed off; I will rub it into the baby’s skin. The baby’s first bath is to be delayed for at least 24 hours. If I have already been discharged, I will bathe it at home.

 

Labor and Delivery Nurse Care Plan

This is an abbreviated list to be given to the LDR nurses in case your Dr/CN Midwife has not arrived. A more detailed list should be worked through ahead of time with your labor attendant and a copy should be in your file. Always have extra copies of your birth plan and baby plan with you.

Birth Instructions for (Patient’s Name)

The following instructions are to be followed as long as the mother and baby’s well‐being are not jeopardized by them.

  1. No routine prep. (Enema, shaving, or I.V.)
  2. Vaginal exams. Initial exam upon arriving and only when I ask to be checked after that.
  3. Fetal Monitoring will be done with a fetoscope only unless requested by my birth attendant.
  4. Light food and clear liquids will be given if requested.
  5. I want to control pushing with instructions on when not to push.
  6. Episiotomy – Perineal support and guidance of the baby’s head to prevent superior tearing should be performed. I would prefer to be allowed to tear a small amount with an episiotomy performed only if the tear is going toward my clitoris or rectum.
  7. Forceps/Vacuum Extraction should not be used unless the baby’s life is threatened.
  8. Breaking/Stripping the membranes – Bag of waters is to be allowed to break on its own. If my labor stalls for an extended period of time, I would appreciate having this option first discussed with me.
  9. Pain medication during labor should not be offered. If I decide to use pain medication, I would prefer a fast acting, short half‐life general anesthetic to an epidural.
  10. 10. Contraction inducing drugs (ie. Pitocin) – I would appreciate every step possible beingtaken to avoid the necessity of using this drug both before the baby is born and for expelling the placenta.
  1. Please allow the placenta to be expelled on its own, with no pulling or tugging.
  2. Do not cut the cord until it has stopped pulsating. Also, please do not milk the cord to speed this process.
  3. I do not want the baby’s air passages suctioned automatically if it is attempting to clear them on its own (coughing, sneezing).

Thank you!

________________________________________

Submit a Comment

Your email address will not be published. Required fields are marked *