Plan, Sample 1
Birth Plan For:
[name (husband's name)]
Obstetrician: _________ Doula: _________ Hospital: _________
My husband, __________, and
the doula, _____ _____, should be present with me throughout
labor and delivery.
Corrective Lenses: I
need to wear contact lenses or glasses at all times when conscious,
as my vision is so bad that being without corrective lenses
is unbearably disorienting. This should not be a problem, as
my contact lenses take very little time to remove in the event
of an emergency, and furthermore are extended wear, so there
would be no problem if they were left in my eyes for an extended
period of time, up to a week, including periods of sleep. My
husband will have my glasses in case I need to remove my lenses.
External Fetal Monitoring:
We do not wish to have continuous fetal monitoring unless required
by the condition of the baby. We expect that there will be a
period of being monitored by the external fetal monitoring upon
first arriving at the hospital, and afterwards monitoring will
be intermittent as long as everything looks ok.
Prep: I would prefer
to avoid an enema or extensive shaving of pubic hair.
Free Movement: I wish
to be able to move around and change position at will throughout
labor. I would like to be allowed to choose the position in
which I give birth, including squatting.
IV: I do not want an IV unless I become dehydrated. If necessary,
I will accept having a device (heparin lock?) inserted into
a vein so that an IV can be started up quickly when needed,
but without the IV being connected until it is needed.
Artificial Rupture of
Amniotic Membrane: I do not wish to have the amniotic membrane
ruptured artificially before the birth unless signs of fetal
distress require an internal monitor. I do not want the internal
monitor unless the baby has already shown some sign of distress.
Fluids by mouth throughout
first stage of labor.
Anesthesia and Pitocin:
I do not wish to use any anesthesia unless I request it during
labor. I will want local anesthesia for repair of tears or of
episiotomy, of course. I do not want routine pitocin to be used;
we should be allowed to try position changes and nipple stimulation
before pitocin is used.
Episiotomy: I do not
wish an episiotomy unless required to avoid an extensive tear.
I would prefer a medium-sized tear to an episiotomy, although
I imagine that it may be hard to judge how much tearing will
occur. I intend to take all possible measures to avoid the need
for an episiotomy.
Birth: I would like
to be allowed to hold the child immediately after birth. We
would prefer that the cord not be cut immediately, but given
a few minutes to cease functioning first.
Ceasarian: If a ceasarian
is necessary, I wish to have an epidural for anesthesia, and
to have my husband and, if possible, [the doula's name] present
for the birth. The child, if he is not in distress, should be
given to my husband.
Circumcision: We do
not wish to have circumcision performed in the hospital. (Better
to go to a specialist who uses local anesthesia, if you want
Breastfeeding: I intend
to breastfeed the infant and do not wish to have any bottles
given to him, including glucose water. [This was not followed,
which caused big troubles!!!]
Rooming-in: We would
like to have the baby remain with us in our room. We do not
want the baby to be taken away from us unless he requires medical
treatment, or unless we request to have him taken to the nursery.
We would like to have the baby examined in our presence.