choices in childbirth

CHOICES IN CHILDBIRTH'S BIRTH PLAN ORGANIZER

Name: __________________________________________________________________________________________

Due Date: _________________________________________________________________________________________

Midwife/Doctor: _________________________________________________________________________________________

Doula: __________________________________________________________________________________________

Birthing Center/ Hospital: ________________________________________________________________________________________

Below is an outline of my preferences for the upcoming birth of my child. I realize that there are circumstances that may preclude some of the choices I have made, and I will be flexible should my options change.

Introducing myself:

Important Issues, Fears or Concerns:

During the First Stage of Labor, my preferences are:

ENVIRONMENT

__ Wear my own clothes

__ Wear hospital gown

__ Lights kept dimmed

__ Music of my choice

__ Silence

__ Door kept closed at all times

__ Curtain kept drawn in front of door

SUPPORT

__ Partner present during all aspects of labor and birth

__ Doula support

__ Other family present

__ Medical students may/may not perform medical procedures

__ Limit amount of extra personnel in the room

MOBILITY

__ Change positions for comfort and progress in labor

__ Freedom to utilize shower or bath as needed for pain relief

__ Use of Birth Ball for back pain relief

VAGINAL EXAMINATIONS

__ Limited vaginal exams

__ Vaginal exams done only by nurse or doctor/midwife, no students or residents

__ Students or residents may perform vaginal examinations

FOOD/FLUIDS

__ Eat and drink as desired during labor

__ Fluids only

__ Ice Chips only

__ IV for hydration

__ No IV

__ Heparin Lock

ELECTRONIC FETAL MONITORING

__ Intermittent external auscultation of baby with hand-held Doppler

__ Intermittent external auscultation of baby with EFM machine

__ Continuous external/ internal auscultation of baby with EFM machine for high risk labor or medical circumstance.

INDUCTION/AUGMENTATION

__ Prefer natural methods

__ Herbal products suggested by doctor or midwife

__ PGE2 Gel

__ Pitocin

__ No Amniotomy unless medically necessary

PAIN RELIEF OPTIONS:

__ Support from partner, doula, staff

__ Shower, Bath or Jacuzzi

__ Position Changes as needed

__ Birth Ball

__ Walking

__ Pelvic Rocking

__ Massage

__ Acupressure

__ Rebozo shawl or sheet for back pain or positional relief

__ Relaxation, Breathing, Visualization techniques

__ Alternate between heat/cold

__ Focal Point

__ Keep my bladder as empty as possible

__ Medication only if requested

__ Staff is requested to not offer medication throughout labor

__ Medication in Active Labor

__ Analgesics or Narcotics: _______________

__ Regional Anesthesia: Epidural*

During the Second Stage of Labor (Pushing), my preferences are:

POSITIONS for SECOND STAGE

__ My choice of positions

__ Utilize Squatting Bar

__ Stirrups or foot rests

__ No stirrups or foot rests

__ Natural support for legs

__ Avoid supine positioning

PUSHING TECHNIQUE

__ Spontaneous bearing down

__ Directed pushing

__ No time constraints as long as baby is fine

__ Prolonged breath-holding pushing technique with nurse or medical staff guiding the length of effort**

PERINEUM

__ No Episiotomy

__ Warm Compresses

__ Lubricating Oil

__ Natural tearing ok

__ Episiotomy with local anesthesia

__ Pressure Episiotomy

Once the baby is born, my preferences are:

BIRTH

__ Partner to cut the cord

__ Wait until cord stops pulsating

__ Doctor or midwife allowed to Clamp and cut cord immediately**

__ Baby placed on mom right away

__ Baby cleaned off rig

BREASTFEEDING

__ Breastfeeding as soon as baby is ready

__ Lactation Specialists to assist me if necessary

__ If my baby and I are separated, no supplementation of formula is to be offered. I will pump breast milk and baby will be offered breast milk via syringe, cup or SNS.

__ No artificial nipples (bottles or pacifiers) are to be offered to the baby.

NEWBORN CARE

__ Baby to stay with me at all times unless there is a medical emergency.

__ Delay routine procedures (cleaning, weighing, measuring, ointment in eyes) until after my initial recovery period of at least 2 hours.

__ Baby to room-in with me.

__ Other: