Birth Plan
Due date:
I would like to have a quiet labour and delivery with very minimal people in the room. Please talk to
my husband first regarding anything that might come up during my labour. I would prefer to hear it
from him rather than being pushed to make a decision while I am in labour.
Labor:
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❖ I would like to be able to change positions at will, stand, and/or walk around throughout
labor.
❖ If I test positive for Group B Strep, I understand that administration of the antibiotics takes 30
minutes. After that time, I would like the IV to be disconnected (with the Saline Lock remaining
in place) so that my ability to move is not restricted.
❖ I would appreciate access to a birthing ball and do my labour and birth in water
❖ I would like support with use of comfort measures, relaxation, and breathing to facilitate
progress with labor, reduce my fear and tension, and the need for medical intervention.
Monitoring:
❖ Due to restrictions upon movement, I would prefer the baby be monitored intermittently or
by telemetry unit.
Labor Induction and Augmentation: ❖ If my water has broken, I would prefer to wait rather
than to be administered Pitocin immediately. We would like my temperature to be monitored
for infection and, if infection is not present, wait 12 hours to see if contractions begin naturally.
If they do not begin after 12 hours, administration of Pitocin may begin.
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❖ I would prefer that the membranes not be routinely, artificially ruptured.
Anesthesia:
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❖ I would like to attempt to have a natural/unmedicated labor/delivery, however, if I request
an epidural, please give me additional support (comfort measures), prior to honoring my
request. I have discussed this with our Midwife who understands my wishes. If I then repeat the
request after comfort measures have been tried please give me the epidural.
❖ Do NOT ask me if I want pain medication. I know what it is and will ask for it twice if I want it.
Cesarean:
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❖ I would like My husband to remain with me in case of an unexpected caesarean.
❖ My husband would like to be given the option to hold the baby while my incisions are being
repaired.
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❖ My husband is to remain with the baby if it is necessary to remove him/her from the room
and my midwife to remain with me.
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Perineum:
❖ I would prefer not to have an episiotomy. I would rather risk tearing.
❖ In a non-emergency situation, I would prefer to tear rather than have an episiotomy.
❖ I would like warm compresses applied to the perineum and slow crowning of the baby’s head
to prevent tearing.
❖ I would prefer that olive oil of which we will supply be used to assist the stretching of my tissues
during crowning. Please do not massage my perineum, just apply the oil.
Delivery/After Delivery:
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❖ I would like to be able to change pushing positions, as applicable rather than be confined to
one position.
❖ My husband would like to be given the option to catch the baby as it emerges.
❖ I would like the baby placed directly on my stomach/chest with skin-to-skin contact
immediately after delivery, while baby is being observed, and Apgar score is determined.
❖ We would prefer that the cord not be cut until it has stopped pulsating AT LEAST 3 minutes.
❖We DO NOT want antibiotic ointment to be applied to baby’s eyes.
Baby Care Plan
(THIS IS FOR THE BABY’S NURSE)
Breastfeeding:
❖ I would like to breastfeed the baby within minutes of birth.
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❖ To promote breastfeeding and bonding, we would prefer that a pacifier, bottle of water or
glucose water NOT be given to the baby. I will be feeding on demand.
Immunizations:
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❖ We would like our baby to be immunized.
Other:
❖ Please administer vitamin K shot to our baby while he/she is lying on me, but NOT before
30 minutes have elapsed from the time of birth.
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❖ We would prefer our baby not to be bathed. If we want to bath our baby, please do it just
before discharge. We want the vernix to be fully absorbed
❖ We would like to have the baby bathed and examined in our presence. Or We DO NOT want
out baby bathed at any time.
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❖ We will NOT be sending the baby to the nursery at ANY time, please make arrangements for
ALL care of our baby to happen in our room at bedside. This includes check-ups, monitoring and
pediatrician visits. The only exception to this is emergency care via the NICU. NO routine
observations will be done in the nursery.
Again, thank you for your help and support during this important event in our lives.
Signed:
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