BIRTH PLAN

Due: Jan. 1, 2018
Mom: Janey
111-1111

Partner: George
222-2222
Support: Betty (Doula)
Health Provider: Core Health Group
Delivery Person: City Center Midwives
Pediatrician: Dr Johnson
These are my preferences, goals, and boundaries for a normal and healthy birth. If an emergency arises, I ask for the least invasive procedure possible and would like to be informed before any interventions take place. Please honor the items below when possible. My sister, Julie will be in the waiting room during the delivery. In case of emergency please contact her at 333-3333. If the baby needs to go to the NICU, please have my sister stay with the baby at all times.
LABOR
BIRTH
Vaginal delivery
Dim lights
Peace and quiet
Immediate skin-to-skin
Delay cord clamping until pulsing stops
Partner to cut cord
Free movement
Use birthing tub during labor
No pain medication
Cord blood to be donated
Examine baby on mom's chest
Hep B OK
Natural water rupture
No episiotomy, avoid tearing
No pitocin
Vit K OK
Eye ointment OK after 1 hr
Baby stays in room with mom
No unnecessary interventions
Saline lock only
Intermittent baby monitoring
No soap for baby bath
blank
blank


Make sure to print in landscape orientation.