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Birth Plan
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Birth Plan
http://www.ultimatepregnancysecrets.com
experiences that they do not want to miss because of the blur and rush of delivery; During the Hospital Stay - here is the area for your feeding preferences for the new born, where you want the baby to stay, if a partner is to stay with you, and more; and In the Event of Trouble - this is the proverbial "gray area" that most parents dread. This is the spot to indicate your preferences for any of those "what if" scenarios.
Now that you understand the basic order of things, we can get started in making the specific choices and writing them down in the plan. Remember to be sure to give copies of this to your medical provider, your partner, and to ensure that everyone involved in the birthing process has reviewed your wishes as stated in the document.
General Information
Full Name: Partner's Name: Due Date/Date of Induction: Doctor's Name: Hospital Name: Name of Alternative Care Provider (i.e. Doula, Midwife, etc.): Primary Language: Religious Customs to be observed:
Medical Details
Note that I have: Group B Strep Rh Incompatibility with my Baby Gestational Diabetes
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Labor Preferences
During labor I would like: My partner with me the entire time Hydration with clear liquid The option to eat and drink if approved by my physician Minimal vaginal exams Limited interruptions Staff limited only to my doctor and the nurses on duty (No students, interns, residents, etc.)
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Camera or video device used by my partner/support Music (I will bring from home) Dim Lights Quiet Room conditions
Fetal Monitoring
I want: External Internal Continuous Intermittent Audible Inaudible
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Augmentation
I will agree to labor augmentation only if: Baby is in distress Natural methods fail to generate results Membrane stripping is used Prostaglandin gel is used Pitocin is used Rupturing of membrane is used Rupturing or stripping of membranes is NOT used
Pain Management
I would prefer to use: Acupressure Acupuncture Breathing Cold/Hot Therapies Demerol Epidural Hypnosis Massage Meditation Reflexology TENS Nothing What I might request at the time
Birth Plan
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Delivery Preferences
Stage 2 Labor - Pushing and Positions
The position I would prefer to deliver is: Semi-Reclined Lying on my side Lying on my back Squatting Hands and knees Standing With leg support With stirrups With a birth bar With a birth stool In a birthing tub In the shower
Birth Plan
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Pushing
During the delivery process I want to: Push as directed Push when I feel the need Push without a fixed time limit (unless baby is at risk) See the crowning with a mirror Touch the head as I crown Allow the epidural to wear off at the end of delivery Use the entire dose of epidural Have no forceps used Have no vacuum extraction Help to catch my baby Have my partner catch the baby Let my partner suction the baby's airways Use whatever methods are necessary
Episiotomy
If at risk: Prefer not to perform (even if tearing is possible) Only as last resort Only if doctor deems necessary With anesthesia Without anesthesia
Birth Plan
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Post-Delivery Wishes
Immediately after delivery
I want: My partner to cut the cord The cord to be cut after pulsating stops The cord blood to be harvested for a bank (List bank: The cord blood to be donated (List organization: To pass the placenta without augmentation To see the placenta ) )
If a C-Section is Recommended
I would like: To exhaust my other options Get a second opinion Remain awake To have my partner with me throughout No screening in order to see delivery To have the surgeon explain each process as it occurs To have an epidural For my partner to catch the baby
Birth Plan
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Breastfeeding
I want to: Feed immediately after delivery Before eye care is done Later Not at all
Support Options
I want my family to: Be with me after delivery To meet me in my room To see baby only in nursery To have unlimited visitation
To exclude:
Antibiotic eye ointment Exclude immunizations until a later date Formula
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First Bath
I want to bathe my baby I want my partner to bathe the baby I want it done in my presence I want it done in my partner's presence
Feedings
Only with my breast milk Only with formula When required On a schedule With support of lactation expert
Partner
I want my partner to: Have unlimited visitation
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Circumcision
I prefer: No circumcision Circumcision To be performed later With anesthesia To be done only in my presence or my partner's
My Comfort
Please give me: Acetaminophen as needed Percoset as needed Stool softener is required Laxative if required I would like to stay as long as possible I would like to go home as soon as possible