create your birth plan with our print-out template!
While much of what happens during delivery is way beyond your (or anyone's!) control, creating a birth plan will at least make your wishes clear. Definitely talk the plan over with your doc -- it's important to make sure you're both on the same page. Also, remember that the options included on our plan may not be available with every doctor or birthing center.
重新掌握
有別於以往單純遵照產檢結果與醫師指示，三軍總醫院婦產部染色體檢驗中心主任黃貴帥和產房副護理長呂美芬皆表示，訂立生產計畫書，能夠幫助準媽媽更了解自己的狀況，更重要的是擁有對身體的控制感。
黃貴帥醫師說明，準媽媽可選擇以最少醫療介入的方式生產，如不需剃毛和灌腸、產前無需禁食（可補充好消化的食物，如流質或軟質食物）、減少內診次數 和胎兒監視器測試等等；準媽媽可以事先做好計畫與準備，共同和協助生產的醫療團隊討論及參與過程。呂美芬副護理長建議，孕媽咪藉由主動詢問醫護人員，或參 與各醫院的媽媽教室課程，將能獲得更完整的生產計畫書概念，自然可以了解自己最需要和想要的是什麼樣的生產過程。
親密關係
不只是白紙黑字的約定而已，醫師楊政憲強調，生產計畫書更強化了家人間的親密感與醫民間的信任關係。他表示，生產計畫書包
括縱與橫的面向：以時間為縱軸，從「待產→生產→產後」俱全；以三階段為橫軸，從待產環境、生產姿勢、產後親子同室……各自發展細節。而這裡的每一項，都
需要家人間共同的關懷與討論、家人與醫護人員的信賴與溝通，才能夠構築出準媽媽最安心的生產環境。
楊政憲醫師認為，「父親」這角色，在準媽媽孕產過程中占有相當份量。傳統的爸爸對於孕產過程總是處於無助的立場；藉由生產計畫書，父親不但有了參與感，進而和即將成為母親的她建立共同的情感羈絆，讓生產不再只是獨力奮鬥的痛苦過程。
生命體驗
以往在胎兒離開母體後，總是快速地被醫師剪斷臍帶並進行後續處理。但黃貴帥醫師表示，現代不少爸爸除了拍攝生產過程外，還親手幫寶寶剪臍帶！當親眼、親手接觸生命的誕生，意義自然不同凡響。
在強調親子同室的現代，呂美芬副護理長補充，胎兒離開母體，由醫護人員協助新生兒護理，隨即抱到媽媽身上做肌膚接觸，儘早建立彼此的熟悉感，更增加母乳哺餵成功機會。這些人性化的生命體驗，絕對是能夠被討論、而以計畫書來執行的。
SAMPLE 1
Birth Plan:
[ ] Full name:
[ ] Partner’s name:
[ ] Today’s date:
[ ] Due date: OR Induction date:
[ ] Doctor’s name:
[ ] Hospital name:
Please note that I:
[ ] Have group B strep
[ ] Am Rh incompatibility with baby
[ ] Have gestational diabetes
My delivery is planned as:
[ ] Vaginal
[ ] C-section
[ ] Water birth
[ ] VBAC
I’d like…:
[ ] Partner:
[ ] Parents:
[ ] Other children:
[ ] Doula:
[ ] Other:
…present before AND/OR during labor
During labor, I’d like:
[ ] Music played (I will provide)
[ ] The lights dimmed
[ ] The room as quiet as possible
[ ] As few interruptions as possible
[ ] As few vaginal exams as possible
[ ] Hospital staff limited to my own doctor and nurses (no students, residents or interns present)
[ ] To wear my own clothes
[ ] To wear my contact lens the entire time
[ ] My partner to film AND/OR take pictures
[ ] My partner to be present the entire time
[ ] To stay hydrated with clear liquids and ice chips
[ ] To eat and drink as approved by my doctor
I’d like to spend the first stage of labor:
[ ] Standing up
[ ] Lying down
[ ] Walking around
[ ] In the shower
[ ] In the bathtub
I'm not interested in:
[ ] An enema
[ ] Shaving of my pubic area
[ ] A urinary catheter
[ ] An IV, unless I’m dehydrated (and a heparin or saline lock IS/IS NOT ok)
I’d like fetal monitoring to be:
[ ] Continuous
[ ] Intermittent
[ ] Internal
[ ] External
[ ] Performed only by Doppler
[ ] Performed only if the baby is in distress
I’d like labor augmentation:
[ ] Performed only if baby is in distress
[ ] First attempted by natural methods such as nipple stimulation
[ ] Performed by membrane stripping
[ ] Performed with prostaglandin gel
[ ] Performed with Pitocin
[ ] Performed by rupture of the membrane
[ ] Performed by stripping of the membrane
[ ] Never to include an artificial rupture of the membrane
For pain relief, I’d like to use:
[ ] Acupressure
[ ] Acupuncture
[ ] Breathing techniques
[ ] Cold therapy
[ ] Demerol
[ ] Distraction
[ ] Hot therapy
[ ] Hypnosis
[ ] Massage
[ ] Meditation
[ ] Reflexology
[ ] Standard epidural
[ ] TENS
[ ] Walking epidural
[ ] Nothing
[ ] Only what I request at the time
[ ] Whatever is suggested at the time
During delivery, I would like to:
[ ] Squat
[ ] Semi-reline
[ ] Lie on my side
[ ] Be on my hands and knees
[ ] Stand
[ ] Lean on my partner
[ ] Use people for leg support
[ ] Use foot pedals for support
[ ] Use a birth bar for support
[ ] Use a birthing stool
[ ] Be in a birthing tub
[ ] Be in the shower
I will bring a:
[ ] Birthing stool
[ ] Birthing chair
[ ] Squatting bar
[ ] Birthing tub
As the baby is delivered, I would like to:
[ ] Push spontaneously
[ ] Push as directed
[ ] Push without time limits, as long as the baby and I are not at risk
[ ] Use a mirror to see the baby crown
[ ] Touch the head as it crowns
[ ] Let the epidural wear off while pushing
[ ] Have a full dose of epidural
[ ] Avoid forceps usage
[ ] Avoid vacuum extraction
[ ] Use whatever methods my doctor deems necessary
[ ] Help catch the baby
[ ] Let my partner catch the baby
[ ] Let my partner suction the baby
I would like an episiotomy:
[ ] Used only after perineal massage, warm compresses and positioning
[ ] Rather than risk a tear
[ ] Not performed, even if it means risking a tear
[ ] Performed only as a last resort
[ ] Performed as my doctor deems necessary
[ ] Performed with local anesthesia
[ ] Performed by pressure, without local anesthesia
[ ] Followed by local anesthesia for the repair
Immediately after delivery, I would like:
[ ] My partner to cut the umbilical cord
[ ] The umbilical cord to be cut only after it stops pulsating
[ ] To bank the cord blood
[ ] To donate the cord blood
[ ] To deliver the placenta spontaneously and without assistance
[ ] To see the placenta before it is discarded
[ ] Not to be given Pitocin/oxytocin
If a C-section is necessary, I would like:
[ ] A second opinion
[ ] To make sure all other options have been exhausted
[ ]To stay conscious
[ ] My partner to remain with my the entire time
[ ] The screen lowered so I can watch baby come out
[ ] My hands left free so I can touch the baby
[ ] The surgery explained as it happens
[ ] An epidural for anesthesia
[ ] My partner to hold the baby as soon as possible
[ ] To breastfeed in the recovery room
I would like to hold baby:
[ ] Immediately after delivery
[ ] After suctioning
[ ] After weighing
[ ] After being wiped clean and swaddled
[ ] Before eye drops/ointment are given
I would like to breastfeed:
[ ] As soon as possible after delivery
[ ] Before eye drops/ointment are given
[ ] Later
[ ] Never
I’d like my family members (NAMES):
[ ] To join me and baby immediately after delivery
[ ] To join me and baby in the room later
[ ] Only to see baby in the nursery
[ ] To have unlimited visiting after birth
I’d like baby’s medical exam and procedures:
[ ] Given in my presence
[ ] Given only after we’ve bonded
[ ] Given in my partner’s presence
[ ] To include a heel stick for screening tests beyond the PKU
[ ] To include a hearing screening test
[ ] To include a hepatitis B vaccine
Please don’t give baby:
[ ] Vitamin K
[ ] Antibiotic eye treatment
[ ] Sugar water
[ ] Formula
[ ] A pacifier
I’d like baby’s first bath given:
[ ] In my presence
[ ] In my partner’s presence
[ ] By me
[ ] By my partner
I’d like to feed baby:
[ ] Only with breastmilk
[ ] Only with formula
[ ] On demand
[ ] On schedule
[ ] With the help of a lactation specialist
I’d like baby to stay in my room:
[ ] All the time
[ ] During the day
[ ] Only when I’m awake
[ ] Only for feeding
[ ] Only when I request
I’d like my partner:
[ ] To have unlimited visiting
[ ] To sleep in my room
If we have a boy, circumcision should:
[ ] Be performed
[ ] Not be performed
[ ] Be performed later
[ ] Be performed with anesthesia
[ ] Be performed in the presence of me AND/OR my partner
As needed post-delivery, please give me:
[ ] Extra-strength acetaminophen
[ ] Percoset
[ ] Stool softener
[ ] Laxative
After birth, I’d like to stay in the hospital:
[ ] As long as possible
[ ] As briefly as possible
If baby is not well, I’d like:
[ ] My partner and I to accompany it to the NICU or another facility
[ ] To breastfeed or provide pumped breastmilk
[ ] To hold him or her whenever possible
SAMPLE 2
GENERAL INFORMATION:
Birth Plan for the _________________________ family.
Mother's first and last name:
Father's first and last name:
Due Date:
Coach's first and last name:
Other support people:
Name of obstetrician:
Desired hospital:
EARLY/FIRST STAGE LABOR
Environment
Low lighting
Quiet room
Music
Wear own clothing
Coach/partner only desired attendees other than medical staff
I would prefer to wear my contact lenses/glasses
I want my labor and delivery photographed/video recorded
I do not want my labor and delivery photographed/video recorded
Other _______________________________________________
Mobility
choose one:
Unlimited freedom to move (walking, bathroom, rocking chair, fitness ball, etc.)
Mobility is not important to me
Shaving/Enema
{most hospitals no longer shave the pubic area or use enemas, but just in case...}
I would like to avoid the use of an enema.
I would like to avoid having my pubic area shaved.
I.V.
I.V. insertion is acceptable at any point
I.V. placement should be attempted only if dehydration occurs
Please attempt to insert I.V. on left/right (circle)
Hydration
No restrictions
Clear fluids
Ice chips
IV
Monitoring
choose one:
Intermittent monitoring (Fetoscope, Doppler, etc.)
Continuous monitoring (External leads, internal monitoring)
No monitoring except in emergency situations
Catheritization
I would like to avoid catheterization unless it is absolutely necessary
Pain Relief Offer
choose one:
Do not offer; I will ask if I desire it
Offer if I appear uncomfortable
Offer as soon as possible
Pain Relief Options
Natural
Relaxation techniques
Hot or cold compresses
Positioning
Water therapy (bath, whirlpool, shower)
Massage
Accupressure
Hypnotherapy
I.V. Medication
Stadol
Nubain
Demerol
Other ______________________________
Epidural
Walking epidural
Traditional epidural
Labor Induction/Augmentation
No induction
No augmentation
Cervical gel
Pitocin
Rupturing of the amniotic sac
I prefer my amniotic sac be allowed to rupture on its own
SECOND STAGE LABOR
Pushing
{check all pushing options which are acceptable}
Push in position of my choosing
Squat/Birthing Bar
Pushing while on hands and knees
I am not concerned with positioning
Foot pedals rather than stirrups
People as leg support rather than stirrups
Spontaneous pushing (when I feel the need)
Pushing with medical direction
Delivery
I would like to touch baby's head when it crowns
I would like a mirror available to view pushing/crowning/birth
IMMEDIATELY FOLLOWING DELIVERY
I want baby placed on my chest immediately after birth
I would like my partner/coach to cut the cord
I would like to cut the cord
Partner/coach does not want to cut cord
Please delay cord clamping and cutting until pulsating ceases
I would like to hold the baby while delivery placenta
I do not wish a pitocin injection to assist with placenta delivery
I wish baby to be examined in my presence.
If baby cannot be examined in my presence, I wish my partner/coach to remain with baby at all times
I do not wish baby to be placed under heat lamps; I will hold baby and provide body warmth instead
I want to donate cord blood
I want to bank cord blood
EPISIOTOMY
I do not want an episiotomy unless there is an emergency situation
I would like to attempt perineal massage to stretch the perineum.
I would like an episiotomy to reduce risk of tearing
I would like a local anesthetic during repair of tear/episiotomy
I would not like a local anesthetic during repair of tear/episiotomy
BABY CARE
I wish to breastfeed exclusively
I wish to breastfeed, but formula supplementation is acceptable
I wish to formula feed
I do not want baby to be given a pacifier
I would like to meet with a lactation consultant as soon as possible
I want baby circumcised
I do not want baby circumcised
PRIVACY
I would like a private room, I understand that there will be an additional charge
I would like baby to "room in"
I would like baby to sleep in nursery
I would like baby to be brought to me for all feedings
I welcome all well wishers
I wish to limit visitors
I would prefer my door closed with a sign requesting that visitors and staff members knock before entering
I do not wish to have medical students involved in my care
Other ___________________________________________
CESAREAN
In the event that a cesarean section is deemed necessary, I would like the following:
Partner/coach present
Other support present _________________________
Pictures/video
Screen lowered at delivery
I would like the procedure described as it is happening
Partner would like to cut cord
Other _________________________
In the Event that Baby Requires Special Care Due to Trauma or Illness:
I would like to breastfeed/pump breast milk
Partner/coach will accompany baby if transferred to another hospital
I would like to be transferred to baby's hospital
Mother's Signature __________________________ Date ____________
Father's Signature __________________________ Date ____________
With a well-considered, well-organized plan in place you'll relieve stress by knowing what to expect and by ensuring that your wishes and preferences are known to all - including your doctor.
While much of what happens during delivery is way beyond your (or anyone's!) control, creating a birth plan will at least make your wishes clear. Definitely talk the plan over with your doc -- it's important to make sure you're both on the same page. Also, remember that the options included on our plan may not be available with every doctor or birthing center.
為何需要生產計畫書
早期提到「生產」，腦海浮現的往往脫離不了「痛」、「漫長」等等偏向負面觀感的關鍵字。由於生產是迎接新生命的誕生，其過程的一切理所當然地被賦予為必經的代價與意義；加上以往醫學技術不夠發達，只要能協助安全產下胎兒，就是值得慶幸之事。
在醫學極為進步的現代，人們開始再一次深思「生產」這件事──新生命的降臨是如此美好，為什麼生產過程卻必須是痛苦的？孕育胎兒的媽媽和爸爸，從孕期到產前，除了必經的醫療過程外，能否加入夫妻（親身孕育者）的意見？
重新掌握 
身體自主權
有別於以往單純遵照產檢結果與醫師指示，三軍總醫院婦產部染色體檢驗中心主任黃貴帥和產房副護理長呂美芬皆表示，訂立生產計畫書，能夠幫助準媽媽更了解自己的狀況，更重要的是擁有對身體的控制感。黃貴帥醫師說明，準媽媽可選擇以最少醫療介入的方式生產，如不需剃毛和灌腸、產前無需禁食（可補充好消化的食物，如流質或軟質食物）、減少內診次數 和胎兒監視器測試等等；準媽媽可以事先做好計畫與準備，共同和協助生產的醫療團隊討論及參與過程。呂美芬副護理長建議，孕媽咪藉由主動詢問醫護人員，或參 與各醫院的媽媽教室課程，將能獲得更完整的生產計畫書概念，自然可以了解自己最需要和想要的是什麼樣的生產過程。
親密關係 信任回饋
不只是白紙黑字的約定而已，醫師楊政憲強調，生產計畫書更強化了家人間的親密感與醫民間的信任關係。他表示，生產計畫書包
括縱與橫的面向：以時間為縱軸，從「待產→生產→產後」俱全；以三階段為橫軸，從待產環境、生產姿勢、產後親子同室……各自發展細節。而這裡的每一項，都
需要家人間共同的關懷與討論、家人與醫護人員的信賴與溝通，才能夠構築出準媽媽最安心的生產環境。楊政憲醫師認為，「父親」這角色，在準媽媽孕產過程中占有相當份量。傳統的爸爸對於孕產過程總是處於無助的立場；藉由生產計畫書，父親不但有了參與感，進而和即將成為母親的她建立共同的情感羈絆，讓生產不再只是獨力奮鬥的痛苦過程。
生命體驗 溫柔＆快樂
以往在胎兒離開母體後，總是快速地被醫師剪斷臍帶並進行後續處理。但黃貴帥醫師表示，現代不少爸爸除了拍攝生產過程外，還親手幫寶寶剪臍帶！當親眼、親手接觸生命的誕生，意義自然不同凡響。在強調親子同室的現代，呂美芬副護理長補充，胎兒離開母體，由醫護人員協助新生兒護理，隨即抱到媽媽身上做肌膚接觸，儘早建立彼此的熟悉感，更增加母乳哺餵成功機會。這些人性化的生命體驗，絕對是能夠被討論、而以計畫書來執行的。
找對醫療團隊‧生產好happy
在哪家醫療院所生孩子重要嗎？如果產婦沒有特殊要求的話，當然在哪裡生都差不多；若是產婦有一些特別想法，就有必要事前挑選能符合自身需求的醫療院所，讓生產也能令人感受到有快樂的！
或許因為生得少，愈來愈多的產婦想讓自身的生產經驗有不一樣的感受，而主動選擇與個人理念相同的醫療院所生產。不論是診所或醫院，也愈來愈重視產婦
的個人感受，醫師不再是主要發號施令者，而是強調以「醫療團隊」提供服務，共同為產婦的想法成真而努力，打造一場個人化的生產經驗。SAMPLE 1
Birth Plan:
[ ] Full name:
[ ] Partner’s name:
[ ] Today’s date:
[ ] Due date: OR Induction date:
[ ] Doctor’s name:
[ ] Hospital name:
Please note that I:
[ ] Have group B strep
[ ] Am Rh incompatibility with baby
[ ] Have gestational diabetes
My delivery is planned as:
[ ] Vaginal
[ ] C-section
[ ] Water birth
[ ] VBAC
I’d like…:
[ ] Partner:
[ ] Parents:
[ ] Other children:
[ ] Doula:
[ ] Other:
…present before AND/OR during labor
During labor, I’d like:
[ ] Music played (I will provide)
[ ] The lights dimmed
[ ] The room as quiet as possible
[ ] As few interruptions as possible
[ ] As few vaginal exams as possible
[ ] Hospital staff limited to my own doctor and nurses (no students, residents or interns present)
[ ] To wear my own clothes
[ ] To wear my contact lens the entire time
[ ] My partner to film AND/OR take pictures
[ ] My partner to be present the entire time
[ ] To stay hydrated with clear liquids and ice chips
[ ] To eat and drink as approved by my doctor
I’d like to spend the first stage of labor:
[ ] Standing up
[ ] Lying down
[ ] Walking around
[ ] In the shower
[ ] In the bathtub
I'm not interested in:
[ ] An enema
[ ] Shaving of my pubic area
[ ] A urinary catheter
[ ] An IV, unless I’m dehydrated (and a heparin or saline lock IS/IS NOT ok)
I’d like fetal monitoring to be:
[ ] Continuous
[ ] Intermittent
[ ] Internal
[ ] External
[ ] Performed only by Doppler
[ ] Performed only if the baby is in distress
I’d like labor augmentation:
[ ] Performed only if baby is in distress
[ ] First attempted by natural methods such as nipple stimulation
[ ] Performed by membrane stripping
[ ] Performed with prostaglandin gel
[ ] Performed with Pitocin
[ ] Performed by rupture of the membrane
[ ] Performed by stripping of the membrane
[ ] Never to include an artificial rupture of the membrane
For pain relief, I’d like to use:
[ ] Acupressure
[ ] Acupuncture
[ ] Breathing techniques
[ ] Cold therapy
[ ] Demerol
[ ] Distraction
[ ] Hot therapy
[ ] Hypnosis
[ ] Massage
[ ] Meditation
[ ] Reflexology
[ ] Standard epidural
[ ] TENS
[ ] Walking epidural
[ ] Nothing
[ ] Only what I request at the time
[ ] Whatever is suggested at the time
During delivery, I would like to:
[ ] Squat
[ ] Semi-reline
[ ] Lie on my side
[ ] Be on my hands and knees
[ ] Stand
[ ] Lean on my partner
[ ] Use people for leg support
[ ] Use foot pedals for support
[ ] Use a birth bar for support
[ ] Use a birthing stool
[ ] Be in a birthing tub
[ ] Be in the shower
I will bring a:
[ ] Birthing stool
[ ] Birthing chair
[ ] Squatting bar
[ ] Birthing tub
As the baby is delivered, I would like to:
[ ] Push spontaneously
[ ] Push as directed
[ ] Push without time limits, as long as the baby and I are not at risk
[ ] Use a mirror to see the baby crown
[ ] Touch the head as it crowns
[ ] Let the epidural wear off while pushing
[ ] Have a full dose of epidural
[ ] Avoid forceps usage
[ ] Avoid vacuum extraction
[ ] Use whatever methods my doctor deems necessary
[ ] Help catch the baby
[ ] Let my partner catch the baby
[ ] Let my partner suction the baby
I would like an episiotomy:
[ ] Used only after perineal massage, warm compresses and positioning
[ ] Rather than risk a tear
[ ] Not performed, even if it means risking a tear
[ ] Performed only as a last resort
[ ] Performed as my doctor deems necessary
[ ] Performed with local anesthesia
[ ] Performed by pressure, without local anesthesia
[ ] Followed by local anesthesia for the repair
Immediately after delivery, I would like:
[ ] My partner to cut the umbilical cord
[ ] The umbilical cord to be cut only after it stops pulsating
[ ] To bank the cord blood
[ ] To donate the cord blood
[ ] To deliver the placenta spontaneously and without assistance
[ ] To see the placenta before it is discarded
[ ] Not to be given Pitocin/oxytocin
If a C-section is necessary, I would like:
[ ] A second opinion
[ ] To make sure all other options have been exhausted
[ ]To stay conscious
[ ] My partner to remain with my the entire time
[ ] The screen lowered so I can watch baby come out
[ ] My hands left free so I can touch the baby
[ ] The surgery explained as it happens
[ ] An epidural for anesthesia
[ ] My partner to hold the baby as soon as possible
[ ] To breastfeed in the recovery room
I would like to hold baby:
[ ] Immediately after delivery
[ ] After suctioning
[ ] After weighing
[ ] After being wiped clean and swaddled
[ ] Before eye drops/ointment are given
I would like to breastfeed:
[ ] As soon as possible after delivery
[ ] Before eye drops/ointment are given
[ ] Later
[ ] Never
I’d like my family members (NAMES):
[ ] To join me and baby immediately after delivery
[ ] To join me and baby in the room later
[ ] Only to see baby in the nursery
[ ] To have unlimited visiting after birth
I’d like baby’s medical exam and procedures:
[ ] Given in my presence
[ ] Given only after we’ve bonded
[ ] Given in my partner’s presence
[ ] To include a heel stick for screening tests beyond the PKU
[ ] To include a hearing screening test
[ ] To include a hepatitis B vaccine
Please don’t give baby:
[ ] Vitamin K
[ ] Antibiotic eye treatment
[ ] Sugar water
[ ] Formula
[ ] A pacifier
I’d like baby’s first bath given:
[ ] In my presence
[ ] In my partner’s presence
[ ] By me
[ ] By my partner
I’d like to feed baby:
[ ] Only with breastmilk
[ ] Only with formula
[ ] On demand
[ ] On schedule
[ ] With the help of a lactation specialist
I’d like baby to stay in my room:
[ ] All the time
[ ] During the day
[ ] Only when I’m awake
[ ] Only for feeding
[ ] Only when I request
I’d like my partner:
[ ] To have unlimited visiting
[ ] To sleep in my room
If we have a boy, circumcision should:
[ ] Be performed
[ ] Not be performed
[ ] Be performed later
[ ] Be performed with anesthesia
[ ] Be performed in the presence of me AND/OR my partner
As needed post-delivery, please give me:
[ ] Extra-strength acetaminophen
[ ] Percoset
[ ] Stool softener
[ ] Laxative
After birth, I’d like to stay in the hospital:
[ ] As long as possible
[ ] As briefly as possible
If baby is not well, I’d like:
[ ] My partner and I to accompany it to the NICU or another facility
[ ] To breastfeed or provide pumped breastmilk
[ ] To hold him or her whenever possible
SAMPLE 2
GENERAL INFORMATION:
Birth Plan for the _________________________ family.
Mother's first and last name:
Father's first and last name:
Due Date:
Coach's first and last name:
Other support people:
Name of obstetrician:
Desired hospital:
EARLY/FIRST STAGE LABOR
Environment
Low lighting
Quiet room
Music
Wear own clothing
Coach/partner only desired attendees other than medical staff
I would prefer to wear my contact lenses/glasses
I want my labor and delivery photographed/video recorded
I do not want my labor and delivery photographed/video recorded
Other _______________________________________________
Mobility
choose one:
Unlimited freedom to move (walking, bathroom, rocking chair, fitness ball, etc.)
Mobility is not important to me
Shaving/Enema
{most hospitals no longer shave the pubic area or use enemas, but just in case...}
I would like to avoid the use of an enema.
I would like to avoid having my pubic area shaved.
I.V.
I.V. insertion is acceptable at any point
I.V. placement should be attempted only if dehydration occurs
Please attempt to insert I.V. on left/right (circle)
Hydration
No restrictions
Clear fluids
Ice chips
IV
Monitoring
choose one:
Intermittent monitoring (Fetoscope, Doppler, etc.)
Continuous monitoring (External leads, internal monitoring)
No monitoring except in emergency situations
Catheritization
I would like to avoid catheterization unless it is absolutely necessary
Pain Relief Offer
choose one:
Do not offer; I will ask if I desire it
Offer if I appear uncomfortable
Offer as soon as possible
Pain Relief Options
Natural
Relaxation techniques
Hot or cold compresses
Positioning
Water therapy (bath, whirlpool, shower)
Massage
Accupressure
Hypnotherapy
I.V. Medication
Stadol
Nubain
Demerol
Other ______________________________
Epidural
Walking epidural
Traditional epidural
Labor Induction/Augmentation
No induction
No augmentation
Cervical gel
Pitocin
Rupturing of the amniotic sac
I prefer my amniotic sac be allowed to rupture on its own
SECOND STAGE LABOR
Pushing
{check all pushing options which are acceptable}
Push in position of my choosing
Squat/Birthing Bar
Pushing while on hands and knees
I am not concerned with positioning
Foot pedals rather than stirrups
People as leg support rather than stirrups
Spontaneous pushing (when I feel the need)
Pushing with medical direction
Delivery
I would like to touch baby's head when it crowns
I would like a mirror available to view pushing/crowning/birth
IMMEDIATELY FOLLOWING DELIVERY
I want baby placed on my chest immediately after birth
I would like my partner/coach to cut the cord
I would like to cut the cord
Partner/coach does not want to cut cord
Please delay cord clamping and cutting until pulsating ceases
I would like to hold the baby while delivery placenta
I do not wish a pitocin injection to assist with placenta delivery
I wish baby to be examined in my presence.
If baby cannot be examined in my presence, I wish my partner/coach to remain with baby at all times
I do not wish baby to be placed under heat lamps; I will hold baby and provide body warmth instead
I want to donate cord blood
I want to bank cord blood
EPISIOTOMY
I do not want an episiotomy unless there is an emergency situation
I would like to attempt perineal massage to stretch the perineum.
I would like an episiotomy to reduce risk of tearing
I would like a local anesthetic during repair of tear/episiotomy
I would not like a local anesthetic during repair of tear/episiotomy
BABY CARE
I wish to breastfeed exclusively
I wish to breastfeed, but formula supplementation is acceptable
I wish to formula feed
I do not want baby to be given a pacifier
I would like to meet with a lactation consultant as soon as possible
I want baby circumcised
I do not want baby circumcised
PRIVACY
I would like a private room, I understand that there will be an additional charge
I would like baby to "room in"
I would like baby to sleep in nursery
I would like baby to be brought to me for all feedings
I welcome all well wishers
I wish to limit visitors
I would prefer my door closed with a sign requesting that visitors and staff members knock before entering
I do not wish to have medical students involved in my care
Other ___________________________________________
CESAREAN
In the event that a cesarean section is deemed necessary, I would like the following:
Partner/coach present
Other support present _________________________
Pictures/video
Screen lowered at delivery
I would like the procedure described as it is happening
Partner would like to cut cord
Other _________________________
In the Event that Baby Requires Special Care Due to Trauma or Illness:
I would like to breastfeed/pump breast milk
Partner/coach will accompany baby if transferred to another hospital
I would like to be transferred to baby's hospital
Mother's Signature __________________________ Date ____________
Father's Signature __________________________ Date ____________
With a well-considered, well-organized plan in place you'll relieve stress by knowing what to expect and by ensuring that your wishes and preferences are known to all - including your doctor.
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