Birth Plan

My Estimated Due Date:

Mother:
Father/ Partner:
Baby Gender:
Baby Name:
My Doula:

Overview
We desire a labor and delivery that is as free from medication and other medical interventions
as possible. We strongly prefer a vaginal delivery. Please discuss any suggested interventions or
procedures with all of us and obtain our verbal consent before initiating any such interventions
or procedures. I trust that my practitioner will seek out my opinion concerning all of the issues
directly affecting my birth plan before deviating from it. Thank you for working with us to help
create a positive birth experience for me and my baby.

Pre-Labor
. I would like to go at least 12 to 14 days over my due date before considering inducing labor
. Try natural induction techniques first if induction is indicated.

First Stage Labor

. Husband and doula are to be present at all times

. No “prep”, such as shaving of the pubic hair

. Under any circumstances no enemas
. No IV desired (unless medically needed), no analgesia, no anesthesia
. Very limited vaginal exams
. Absolutely no IFM ( Internal Fetal Monitor )
. Monitored by intermittent monitoring and only external
. No augmentation of labor such as pitocin, ( especially Pitocin) breaking the waters, unless
non-medical techniques are not effective
. No pain medication offered
. Freedom to move/walk around during labor
. Absolutely no placing on my flat back
. Freedom to eat and drink during labor as needed
. I would prefer to wear my own clothes
. If available, I would like to use: a tub, shower, and squatting bar

Second Stage Labor

. Choice of positions for pushing – no stirrups for birth please
. No time limits on pushing if progress is being made
. In case of a “lip” of the cervix remaining, please wait until naturally “disappears”, or pulls back
. Spontaneous bearing down
. Absolutely no Epidural, or other anesthetics
. No episiotomy
. To help prevent tearing, please apply: warm compresses, oil, counter pressure
. No forceps, no vacuum
. No pressure on my abdomen, by anyone!
. No coached pushing, unless medically needed.

Third Stage
. Delay cord clamping and cutting until it has stopped pulsating
. Please allow the father to cut the cord
. Natural delivery of placenta
. No post-delivery pitocin or pulling on the cord please
. No manual uterine exploration please
.I will be taking my placenta home with me, please save it on ice.

After Birth
. I would like my baby placed immediately on my abdomen following the birth
. Baby to breastfeed immediately; please delay newborn procedures until baby has had the
opportunity to breastfeed
.please don’t use any bottles, fake nipple or pacifiers
. I do not consent to the following: erythromycin eye ointment, Hep B vaccination (or any
vaccinations), and circumcision. I will gladly sign my forms to refuse these things.
. Delay the administration of vitamin K up to 2 hours after birth unless medically necessary

. We would like to give our baby its first bath. Please help direct us in this process at the
hospital

We appreciate all that you do. Thank you!