Plan, Sample 3
Dear Dr. _______ and Birth
We are very pleased to be sharing
our birth experience with you. We have worked very hard to make
this pregnancy healthy and low risk and to prepare for the birth
of our first baby: we attended a comprehensive birth class;
read a number of books about pregnancy, labor, delivery, and
child rearing; ___ religiously did 200 Kegel exercises every
day, along with tailor sitting, pelvic rocks, squatting, and
other exercises recommended during pregnancy; faithfully ate
80-100 g. of protein daily, as well as deep green and orange
vegetables, a quart of milk, lots of high-fiber and vitamin
C foods, wheat germ, and even some things never heard of before;
together we practiced relaxation techniques for each stage of
labor, as well as laboring and pushing positions. As you can
see, we did all that is in our power to give our baby a good
start in life. Now, as the pregnancy is approaching its final
weeks, we are eager to share with you, our birth team, our hopes
for a natural and trouble-free birth.
We hope for
a normal, natural birth, and we feel well prepared and look
forward to it. Any help you give us will be most appreciated.
Of course, we realize that unusual circumstances may arise.
It is for that reason that we chose excellent professionals
like you. However, if the course nature takes appears to be
within the limits of the ordinary, we do have preferences regarding
routine hospital procedures for the mother and the baby. These
preferences are expressed in the following Birth Plan.
Birth Plan for
[names of parents]
We would like to be part of the decision-making team and to
be consulted about and asked for our consent before any medical
procedure is performed. We highly value our privacy, so we would
like to keep the birth team to a minimum necessary number, which
excludes residents, trainees, and other nonessential personnel.
We respectfully request that there be as little intervention
as possible unless an emergency arises. This includes: routine
IV, continuous electronic fetal monitoring, use of medications
for pain or labor augmentation, amniotomyand frequent vaginal
We would like
to have freedom of motion and a choice of laboring positions,
particularly in the second stage (this includes the possibility
of a full or partial squatting position).
We ask kindly
that a fetoscope be used for monitoring the baby's heart rate.
We would like
to avoid a routine episiotomy; if one is deemed absolutely necessary,
we would like to try for a pressure episiotomy when the baby's
head is crowning. We would prefer not to use any medication
for labor augmentation or anesthesia.
I would like to breastfeed our baby as soon as she/he is born.
We kindly request that the cord not be clamped or cut before
it has stopped pulsating. We prefer that there be no (or as
little) separation from the baby as possible, particularly in
the early hours after birth. In the case such circumstances
should arise that the baby must be separated from the mother
for a period of time, we would like ________ to be with the
baby at all times. We plan that the baby be breast-fed exclusively,
so we kindly request that no formula or any other kind of supplement
be given to our baby in the hospital.
If the baby
is a boy, we do not want him circumcised.
In the case that a cesarean section needs to be performed, we
would prefer a regional anesthesia that would allow the mother
to be awake and alert for the birth and the father to be present.
If the baby
should need special care, we want to be involved in that care
as much as possible and want the baby breast-fed or given expressed
mother's milk from a bottle.