I made it here.
And added a few alternatives of my own. ^^
And added a few alternatives of my own. ^^
Birth Plan for Stephanie ______ Wise.
Due Date: July 22nd, 2009
Patient of /
Please Note
I would like to wear contact lenses or glasses at all times when conscious.
Labor
Please perform no routine prepatory tasks (shaving, enema, etc.), unless requested.
I expect that doctors and hospital staff will discuss all procedures with me before they are performed.
I would like to be free to walk, change positions and use the bathroom as needed or desired.
I prefer to wear my own clothes, rather than a hospital gown.
I prefer to eat and drink throughout labor, as desired.
I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips).
I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions.
Please limit the number of vaginal exams.
Please allow me to vocalize as desired during labor and birth without comment or criticism.
Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.
To preserve my privacy and dignity, I would prefer that everyone knock before entering.
I will be making the choice of having an epidural during contractions, depending on how much pain I am. And I would like to be notified when the option of having an epidural will become no longer available.
Labor Augmentation/Induction
Please do not rupture my membranes artificially unless medically indicated.
Anesthesia/Pain Medication
I would like to try a narcotic before an epidural.
Cesarean Section Delivery
I feel very strongly that I would like to avoid a cesarean delivery
If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making.
I would like My fiance; Joseph Fleet to be present during the surgery.
Please explain the surgery to me as it happens.
I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.
If possible, please do not strap my arms to the table during the procedure.
If conditions permit, I would like to be the first to hold our baby after the delivery.
If possible, I would like to breastfeed our baby immediately after the birth.
If conditions permit, our baby should be given to My fiance; Joseph Fleet immediately after the birth.
I would like our plans outlined here for after the birth to be followed as closely as possible.
Perineal Care
To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.
I would rather have an episiotomy than risk a tear.
Please administer local anesthesia when repairing any episiotomy or tear(s).
Please suture tears only if necessary.
Delivery
I would like the freedom to push and deliver in any position I like.
I would appreciate help from My fiance; Joseph Fleet and staff supporting my legs as I push.
I would like a soothing environment during the actual birth, with dim lights and quiet voices.
I would like My fiance; Joseph Fleet to help catch our baby.
Immediately after the birth
Please place our baby on my stomach/chest immediately after delivery.
I would like to breastfeed our baby immediately.
My fiance; Joseph Fleet would like the option to cut the cord.
Please remove my IV/Heparin lock/catheter as soon as possible after delivery.
Newborn Care
I would like to hold our baby through delivery of the placenta and any repair procedures.
Please evaluate and bathe our baby at my bedside.
If possible, please evaluate our baby on my abdomen.
If our baby must go to the nursery for evaluation or medical treatment, My fiance; Joseph Fleet, or someone I designate, will accompany our baby at all times.
Postpartum Care
I would prefer not to be catheterized until I've had some private time to attempt urination on my own.
If available, I would prefer a private room.
I would like to have our baby room-in with me at all times.
I would like my My fiance; Joseph Fleet to room-in with me.
Assuming I feel up to it and our baby is healthy, I would like to be released from the hospital as soon as possible following the birth.
I would like permission for access to my chart and our baby's chart.
I would like a cot to be provided for My Fiance; Joseph Fleet, if available.
Feeding/Supplements
I plan to breastfeed and want to nurse immediately following the birth.
Please do not give our baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity.
Unless I am unable to give my consent, please do not give our baby any supplements without first informing me of the reason(s) and seeking my consent.
Please do not give our baby a pacifier.
Additional notes
I am planning for our baby to be circumcised before we check out of the hospital. (Note: Do not waive Vitamin K shot in this event)
During the Circumcision, I would like my partner; Joseph Fleet, to be in the room with him.
Signature of Patient/Mother:
__________________________________
Signature of Fiance/Father:
__________________________________
Due Date: July 22nd, 2009
Patient of /
Please Note
I would like to wear contact lenses or glasses at all times when conscious.
Labor
Please perform no routine prepatory tasks (shaving, enema, etc.), unless requested.
I expect that doctors and hospital staff will discuss all procedures with me before they are performed.
I would like to be free to walk, change positions and use the bathroom as needed or desired.
I prefer to wear my own clothes, rather than a hospital gown.
I prefer to eat and drink throughout labor, as desired.
I will remain hydrated by drinking moderate amounts of fluids (water, juice, ice chips).
I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions.
Please limit the number of vaginal exams.
Please allow me to vocalize as desired during labor and birth without comment or criticism.
Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.
To preserve my privacy and dignity, I would prefer that everyone knock before entering.
I will be making the choice of having an epidural during contractions, depending on how much pain I am. And I would like to be notified when the option of having an epidural will become no longer available.
Labor Augmentation/Induction
Please do not rupture my membranes artificially unless medically indicated.
Anesthesia/Pain Medication
I would like to try a narcotic before an epidural.
Cesarean Section Delivery
I feel very strongly that I would like to avoid a cesarean delivery
If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making.
I would like My fiance; Joseph Fleet to be present during the surgery.
Please explain the surgery to me as it happens.
I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.
If possible, please do not strap my arms to the table during the procedure.
If conditions permit, I would like to be the first to hold our baby after the delivery.
If possible, I would like to breastfeed our baby immediately after the birth.
If conditions permit, our baby should be given to My fiance; Joseph Fleet immediately after the birth.
I would like our plans outlined here for after the birth to be followed as closely as possible.
Perineal Care
To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.
I would rather have an episiotomy than risk a tear.
Please administer local anesthesia when repairing any episiotomy or tear(s).
Please suture tears only if necessary.
Delivery
I would like the freedom to push and deliver in any position I like.
I would appreciate help from My fiance; Joseph Fleet and staff supporting my legs as I push.
I would like a soothing environment during the actual birth, with dim lights and quiet voices.
I would like My fiance; Joseph Fleet to help catch our baby.
Immediately after the birth
Please place our baby on my stomach/chest immediately after delivery.
I would like to breastfeed our baby immediately.
My fiance; Joseph Fleet would like the option to cut the cord.
Please remove my IV/Heparin lock/catheter as soon as possible after delivery.
Newborn Care
I would like to hold our baby through delivery of the placenta and any repair procedures.
Please evaluate and bathe our baby at my bedside.
If possible, please evaluate our baby on my abdomen.
If our baby must go to the nursery for evaluation or medical treatment, My fiance; Joseph Fleet, or someone I designate, will accompany our baby at all times.
Postpartum Care
I would prefer not to be catheterized until I've had some private time to attempt urination on my own.
If available, I would prefer a private room.
I would like to have our baby room-in with me at all times.
I would like my My fiance; Joseph Fleet to room-in with me.
Assuming I feel up to it and our baby is healthy, I would like to be released from the hospital as soon as possible following the birth.
I would like permission for access to my chart and our baby's chart.
I would like a cot to be provided for My Fiance; Joseph Fleet, if available.
Feeding/Supplements
I plan to breastfeed and want to nurse immediately following the birth.
Please do not give our baby supplements (including formula, glucose, or plain water) without my consent, unless there is an urgent medical necessity.
Unless I am unable to give my consent, please do not give our baby any supplements without first informing me of the reason(s) and seeking my consent.
Please do not give our baby a pacifier.
Additional notes
I am planning for our baby to be circumcised before we check out of the hospital. (Note: Do not waive Vitamin K shot in this event)
During the Circumcision, I would like my partner; Joseph Fleet, to be in the room with him.
Signature of Patient/Mother:
__________________________________
Signature of Fiance/Father:
__________________________________
