Plan, Sample 4
My coach will be: ___________________ (husband)
Other support person(s): ______________ (doula)
do not want:
· any induction or augmentation of labor that is not
· medical students, nursing students, interns, or non-essential
medical personnel observing during my labor or during the birth
measures during labor
would like to have the following:
· Use of clear fluids (broth, juice), jello, ice, lollipops,
· Use of my own pillows.
· Use of my own top or gown for labor and delivery.
· Walking around, as tolerated and if safe for baby and
· While in bed, freedom to move and reposition for comfort
will bring a CD player and use music or other recordings for
most helpful things I do when I am uncomfortable are: take warm
baths/showers; receive massage, rock hips.
relax, I listen to soothing music; rock in rocking chair; take
warm showers/baths; use massage and/or aromatherapy.
control for childbirth
have taken a Childbirth Education Course in preparation for
my first child's birth. It used a combination of methods. For
this birth, I have prepared by taking a refresher course with
a local childbirth educator, and by reading several books, including
A Good Birth, A Safe Birth.. I have practiced breathing exercises
and relaxation/stress reduction techniques.
prefer no elective medication; please do not suggest it to me
during labor. If I do request pain relief, I would prefer to
have a fifteen-minute waiting period before the medication is
provided, during which I try alternative methods of relief such
as changing positions, a warm shower, or massage.
needed, I would prefer epidural anesthesia. I understand that
continuous fetal monitoring is required for epidural anesthesia.
would like to avoid other forms IV or IM anesthesia or sedation,
and in particular any medications that are likely to affect
the baby's level of alertness immediately after birth.
PRIOR TO OR DURING EARLY LABOR
I do not want a fleets or a cleansing enema, at home or at the
I do not want to be shaved.
Induction/Augmentation of Labor:
I would like for my labor to proceed at its own natural pace,
and would therefore like to avoid measures such as amniotomy,
stripping of membranes, and/or pitocin unless a specific medical
I understand that intermittent fetal monitoring for assessment
of fetal well-being is recommended by the American College of
Obstetricians and Gynecologists, and that this usually consists
of a 20-30 minute strip upon admission and re-evaluation at
intervals depending on labor progress and fetal response. I
would prefer that this monitoring be kept to an absolute minimum.
I would prefer that the intermittent
monitoring of the baby be done by my midwife using a fetoscope
rather than by electronic monitor, if at all possible.
I do not want internal fetal
monitoring done without a strong medical justification given,
and express permission from me or my husband.
I understand that upon admission blood will be drawn for routine
lab work, and that at that time tubing will remain in place
and a heparin lock created.
If for any reason an IV must be connected, I do not want any
medications administered through the IV without express permission
from me or my husband.
Support of legs by my husband, stepdaughter, and/or nurses,
I would prefer to deliver in a hands-and-knees position if possible.
My second choice is squatting, using my husband and/or the squatting
bar for support.
If the above positions are not possible (due to epidural or
other interventions), I would prefer a left lateral position,
particularly if the baby is in a posterior position.
Elimination of excessive bright light and excessive noise at
Episiotomy only if indicated, if I tear.
I have done perineal massage at home to promote stretching of
I would like perineal massage done during the birthing process.
I would like local anesthesia for repair of lacerations or episiotomy.
Expulsion of Placenta:
I would like to deliver the placenta spontaneously, encouraged
by breast stimulation from the baby suckling.
No one plans to deliver by c/s, but if that becomes an issue,
I would like to have epidural or spinal anesthesia.
My husband and I desire to be together during a cesarean delivery.
I am aware that my husband is there to support me, and that
if general anesthesia is used, that support will not be needed.
However, even if general anesthesia is used, I would like my
husband to be present during the delivery so that he may bond
immediately with the baby while I am still under anesthesia.
If the baby must be taken to the nursery, I would like my husband
to accompany him/her. If I am alert, and the baby is stable,
I wish to hold the baby before it goes to the nursery.
Skin to skin contact on my abdomen as soon as feasible after
Apgar evaluation to be done while baby is on my abdomen.
My husband does not wish to catch the baby or cut the cord.
Prefer that I hold the baby rather than have it placed under
the heat lamps.
Postpone eye medication until after initial bonding is established,
+/- two hours after birth.
Breastfeed as soon as baby and I are ready.
Allow parental/newborn bonding for as long as mother and baby
I would like rooming in 24 hours a day.
We would like to have our 2-year-old son visit baby and me during
my hospital stay.
Pediatric Care and Patient Discharge Preferences
I would like early discharge (24-48 hours) after normal vaginal
delivery. Our pediatrician (family practitioner) has agreed
Our pediatrician (family practitioner) is:
I will have a pediatrician examine the baby while in the hospital.
Case of Medical Problems With Baby
If baby must be taken from room, I would like myself and/or
my husband to accompany the baby at all times.
If medical procedures must be performed on the baby, I would
like for myself and/or my husband to be present at all times.
I plan to exclusively breastfeed our baby, and therefore request
that s/he not be given artificial nipples of any kind, including
bottles (formula or water) or pacifiers.
We have read the information about circumcision. We do not want
our newborn son to be circumcised.