Birth Plan

Birth Plan

To whom it may concern,

I (Mother’s Name), would like to request the below options during my birth at (Facility Name). All procedures and medications will only be given/administered upon my consent. In the case that I am unable to give consent, PARTNER NAME/RELATIONSHIP will make decisions on my behalf. We ask to be accompanied by our doula, NAME for physical, emotional and informative support at all times.

During Labor:

We would like,

Some examples:

• No vaginal exams unless requested

• Relaxing music and dimmed lighting

• Limited hospital staff in room; no students

• No routine IV unless medically necessary, if deemed necessary please use a heparin lock

• Movement for mom

• External Monitors

• Use of essential oils

• Have doula present

After Birth:

We Would like,

Some examples:

• Immediate skin to skin

• Delay cord clamping until pulsating finished, (minimum of 8 minutes)

• Respect of golden hour to include dimmed lighting and hushed voices

Newborn Care:

We would like,

Some examples:

• All routine checks for vital signs are to be done while mother holds baby

• Baby to stay with parents at all times, no nursery visits

• Include whether or not you want your child to be vaccinated (vitamin k and Hep B) and if circumcision is to be performed, as well as eye ointment (for STD prevention)

We thank you in advance for your support, kindness and respect to our choices. We look forward to a wonderful birth.

Signed,