A birth plan is a communication tool between you and your care team. It helps us to know what is most important to you during your baby’s birth and hospital stay. The birth process is unique to each woman and can be unpredictable. You may need to alter your birth plan based on events during your labor and delivery. Emergencies could arise that may cause your care provider to act quickly and deviate from your plan. However, we will always do our best to honor your wishes while protecting you and your baby.

Please ask your care provider to review your birth plan with you, have your provider sign it, and bring the signed copy to your Maternity Navigator visit.

My Name: _____________________________________________________________ Estimated Due Date: _________________________________

My Support Team: _____________________________________________________

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My Care Provider: ______________________________________________________ Signature:___________________________________________

My Baby’s Care Provider: _______________________________________________

1. Comfort Measures and Birth Environment Options to consider:❍ Walking ❍ Labor ball❍ Glider ❍ Shower❍ Labor tub ❍ Music❍ Aromatherapy ❍ Wear own clothes❍ Massage ❍ Hot &/or cold packs❍ ___________________________________________________________

2. Intravenous (IV) Access Options to consider:❍ IV in place with fluids continuously infusing❍ Saline lock inserted in vein but no fluids infusing

3. Monitoring of Contractions and Baby’s Heartbeat Options to consider:❍ Continuous external monitoring of contractions and baby’s heartbeat❍ Intermittent external monitoring of contractions by my nurse by touching my abdomen and monitoring baby’s heartbeat with fetal monitor❍ Use of a wireless monitor so that I can be up and moving during labor. Note: It is important to know that there may be situations when a wireless monitor will not pick up baby’s heartbeat. In this case, you may need to use the monitor at your bedside.❍ ___________________________________________________________

4. Pain Control Interventions Options to consider:❍ Pain medication given through an IV❍ Epidural anesthesia placed by a member of our anesthesia team❍ Please do not mention or offer me pain medications of any kind; I will ask for them if needed.❍ I would like to have an epidural as soon as I am in active labor.❍ ___________________________________________________________

5. Preferences for Pushing and Delivery – Your nurse will explore different pushing and delivery positions based on your preferences and your specific situation.

Options to consider:❍ Spontaneous pushing❍ Pushing with support team guidance❍ Lying on my side ❍ Using a squatting bar❍ Sitting upright in bed❍ Positioned on hands and knees❍ A mirror to watch baby’s head during pushing and delivery❍ ___________________________________________________________

6. Cesarean Section Delivery❍ I would like skin-to-skin contact as soon as possible.❍ I would like _________________________ to accompany me in the operating room (one person).

My Birth Plan Shawnee MissionHealthBIRTH CENTER

SMH# 68172 09/18

7. Umbilical Cord – Optimal cord clamping allows the cord to continue to pulsate for 30 to 60 seconds after the baby is born and is beneficial in most circumstances. If you have plans other than optimal cord clamping, it is important that you discuss them in detail with your care provider.

Options to consider:❍ Having my support person clamp the umbilical cord❍ Having my provider clamp the umbilical cord❍ ___________________________________________________________

8. Cord Blood Collection If you would like to arrange for collection and storage of your baby’s cord blood, you must contact a private company for this and bring the company’s specific collection kit to the hospital on admission. Our staff will be happy to collect the cord blood per their instructions. The company that I plan to use for cord blood collection is: _______________________________________________

9. Placenta Options to consider:❍ Hospital staff will discard placenta❍ I plan to keep my placenta for my own private use if my care provider doesn’t order further testing. If tests are ordered on my placenta, it will not be released to me afterwards. Note: If you plan on keeping your placenta, you must bring a cooler to the hospital on admission to store your placenta, and you must arrange for someone to pick it up soon after delivery.

10. Newborn Care – Your baby will be placed skin-to-skin with you immediately at birth and through the first hour of life providing that you both are stable. Antibiotic ointment for the eyes as well as vitamin K and hepatitis B injections will be given after the first hour.

11. Feeding My Baby – We encourage breastfeeding because it provides the optimal nutrition and immune support for your baby while supporting mom’s health as well. We will assist you with feedings shortly after birth and throughout your stay. My feeding plans are:

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12. Pacifiers – We provide pacifiers for use during painful procedures only.

13. Rooming In – We will support you and your baby in your room 24 hours/day. Your baby may be taken to our Newborn Observation Room for a procedure or if your baby needs closer observation.

14. Circumcision ❍ I wish to have my baby boy circumcised.❍ I wish to not have my baby boy circumcised.

Other wishes for my baby and my birth experience:

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