Birth Plan
Name ________________________________ Signature ______________________________________________
Care Provider__________________ Attending Birth: ______________________________________________
Most Important Issue:
Item Yes No Comments
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1. Labor to begin spontaneously, up to 42 weeks. |
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I am bringing extra pillows or items to help with labor relaxation. |
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2. Ability to move around during labor. |
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3.. Non-clinical pain relief during labor. Massage of hands, feet, back. Optimal Fetal Positioning. |
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Hydrotherapy- tub, shower, water birth, |
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Medication for pain. |
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4. Spontaneous rupture of membranes if warranted |
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5. Minimum amount of fetal monitoring possible. |
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6. Ability to eat and drink during labor. Plans for nourishment. |
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7. Choose position for pushing: Semi-sitting, squatting, supported stand, birth stool, side-lying. |
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8. Perineal hot compresses & olive oil for management of perineum during 2nd stage. |
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9. Touch baby’s head when crowning. |
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10. I would like to lift baby out after head and shoulders are born. |
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11. Cord stopped pulsing before clamping. |
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12. Natural descent of placenta, if possible. |
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13. Baby stays with me at all times. Any procedures done at my bedside, if possible. |
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Partner’s Plan
Name ________________________ Signature _______________________________________________________
Care Provider__________________ Attending birth: ______________________________________________
Most Important Issue:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Item Yes No Comments
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1. In the room for the entire labor. |
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2. Will need to leave at some point. |
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3. Want to be an active part of coaching. |
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4. Would like all procedures, tests, and other interventions explained. |
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5. Am able to stand the sight of blood. |
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6. Would like coaching help from Midwife or Doula. |
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7. Would like to play an active role in the delivery of the baby’s body. |
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8. Special needs or concerns for partner. |
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9. Would like to give baby bath (I will provide little bath tub) |
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10. Other questions or comments |
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Newborn Plan
Name ________________________ Signature ______________________________________________________
Care Provider__________________ Caring for baby after birth: ____________________________________
Most Important Issue: ________________________________________________________________________________________________________________________________________________
Item Yes No Comments
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1. Immediate skin-to-skin contact |
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2. Warmed blankets for mom & I |
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3. Dim lights in room |
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4. I remain with mother for at least one hour after birth to bond. |
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5. Any necessary procedures done on mom’s bed, if possible. |
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6. Breastfeeding as soon as I desire. |
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7. I sleep with mom or in bassinette next to bed. |
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8. Mom and dad would like CPR, infant care information. |
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9. PKU to be done while I am nursing at bedside with mom. |
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10. Circumcision info.? |
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11. I would like a Leboyer Bath. (Mom and dad provide bathtub) |
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12. Mom brings special food to eat for after birth. |
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13. Breastfeeding help if mom needs it. |
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