My Birth Plan:

This birth plan is intended to express the preference and desires we have for the birth of our baby. It is not intended to be a script. We fully realize that situations may arise such that our plan cannot and should not be followed. However, we hope that barring any extenuating circumstances, you will be able to keep us informed and aware of our options. Thank you.

SPECIAL DIET

• Liquid diets only during labor, please do not offer solid food.
• Vegetarian diet but includes dairy and eggs.

LABOR

• I would like to be free to walk around during labor.
• Dim Lights
• Would prefer my own clothes to gown.
• Relaxation techniques (breathing, focusing, etc.)
• Heat or cold packs.
• Massage (back, foot, counter pressure, etc.)
• Positioning as desired.
• Music, aromatherapy.

MONITORING

• Would prefer not to have students, residents etc.
• I do not want an internal monitor.
• Minimal vaginal examinations.

LABOR AUGMENTATION/INDUCTION

• If labor is not progressing, I would prefer to be allowed to try natural methods (walking, nipple stimulation) of advancing labor.
• I would like to have the amniotic membrane ruptured as last resort before other methods are used to augment labor.
• Avoidance of inducing medications such as Pitocin or vaginal tablets

CESAREAN

• NO epidural can be administered due to back conditions and previous spine trauma. In case of emergency, general anesthesia will be administered per Dr. Yaklic’s orders.
• Please use only stitches to close the incision, no staples or glue; **Allergic to topical ointments and Latex!!!

EPISIOTOMY

• Avoid episiotomy
• Provide guidance on when to push and stop pushing

DELIVERY

• Water birth is desired
• I would like to try to wait until I feel the urge to push before beginning the pushing phase.
• I would like to have the baby placed on my stomach/chest immediately after delivery
• Keep vernix on baby.
• No  forceps or vacuum- extraction

IMMEDIATELY AFTER DELIVERY

• I would prefer to hold the baby rather than have (him/her) placed under heat lamps.
• I do not want a routine injection of Pitocin after the delivery to aid in expelling the placenta.
• I would like to give baby first bath.

POSTPARTUM

• I do not wish to be separated from my baby.

BABY CARE

• Breastfeeding only! (No pacifiers. Bottles or glucose water)
• I would like to meet with a lactation consultant.
• No eye medication, we will use colostrums in the baby’s eyes.
• No Vaccinations! Will be administered on a delayed schedule with pediatrician.

SICK BABY

• Breast feeding as soon as possible.
• Please consult us before administering any medications.
• In emergency situation please feed baby pumped breast milk with a syringe (no bottle nipples).

Parent’s signature: _____________________________________________

Physician signature: _____________________________________________

Admitting RN signature: _____________________________________________