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BIRTH PLAN
Information about the mother
Name of the mother:
the field is mandatory
Name of the partner:
Name of the companion/doula:
Due date:
Chosen team/hospital/midwifes:
I would like to store stem cells
Stem cells bank:
Other notes about the mother ()
General requests
I prefer to avoid
enema
shaving my pubic area
I would like
any medical intervention to be explained to me or my partner
dimmed light
peace and quiet as possible
music
to wear my own hospital clothes
Preferably no students, residents or interns or Other people not involved in my birthing process present
A few vaginal exams as possible
I would like my partner to make films or taking pictures
My partner to be present the entire time
Other
First period
Mobility
Preferable no mobility restrictions
Walking
Changing positions
Sitting on the toilet
Shower
Bathtub
Standing up
Using birthing ball
Mobility is not important
Food and beverages
I prefer to stay hydrated and to be able to feed –any possible risks are clarified and I take full responsibility if there are any consequences
I prefer to be hydrated with clear liquids or ice chips–any possible risks are clarified and I take full responsibility if there are any consequences
I prefer to avoid any drinks or food, any possible risks are clarified and I take full responsibility if there are any consequences
Monitoring
I don't mind having continuous fetal monitoring
Preferable intermittent fetal monitoring
Preferable to be aware of any change in my condition
Pain relief
Only if I request for it
Whatever is suggested at the time
Relaxation/meditation
Water - bath, shower, else
Massage
No-spa
Cold therapy
Hot therapy
Standard epidural
TENS
Labor augmentation
Performing pitocin augmentation
Performing prostaglandin gel augmentation
Preferable labor augmentation
Walking and changing positions
Nipple stimulation
I don't mind artificial rupture of the membrane
I don't want artificial rupture of the membrane , unless baby is in distress
I don't want pitocin, unless baby is in distress
Second period
Delivery
Push spontaneously
Push directed
Push without limits ,as long as baby and I are not in risk
Use a mirror to see baby crowning
Touch the head as it crowns
Avoid forceps usage
Avoid vacuum extraction
Help me catch the baby
Let my partner catch the baby
Use whatever methods my doctor deem necessary
Episiotomy
Obligatory
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
Third period
I prefer
Not to be given Pitocin/oxytocin
To deliver the placenta spontaneously and without assistance
To keep placenta
Umbilical cord to be
Cut immediately
Cut only after it stop pulsating
Cut by me
Cut by my partner
I would like to
Donate cord blood
Collect cord blood
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
About the baby
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
I would like to breastfeed
As soon as possible after delivery
Later
Never
On demand
On schedule
Formula feeding
Combine breastfeeding with formula
No water
Separation
I would like baby to stay in my room
not to be separated with the baby during the golden hour
to rest after birth
all the time
only during the day
only when I am awake
only for feeding
only on my request
I would like baby to stay with night nurses
Care
Baths to be given
In My presence
By me
By nurse
Please don't give baby
Vitamin K
Antibiotic eye treatment
Sugar water
Formula
A pacifier
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 me 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
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