Name: __________________________________________________________________________ Baby’s Due Date: _____________________________

Mother’s Doctor/Nurse-Midwife: ________________________________________________________________________________________________

Baby’s Doctor: _________________________________________________________________________________________________________________

Signature: _____________________________________________________________________________________________________________________

A birth plan is a communication tool between you, your doctor or nurse-midwife, your baby’s doctor and your nursing staff. 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. Emergencies could arise that may cause your provider to act quickly and deviate from your birth plan. However, we will always do our best to honor your wishes while protecting you and your baby.

Please have your care providers review and sign your birth plan, then bring a signed copy to your Maternity Navigator visit.

Mother’s Doctor/Nurse-Midwife Signature: _______________________________________________________________________________________

Baby’s Doctor Signature (if birth wishes apply to baby’s care):______________________________________________________________________

Monitoring My Contractions and Baby’s Heart Rate – We routinely use external fetal heart rate and contraction monitoring. Options you might consider are: (Check all that apply)

Checking on the well-being of my baby using intermittent monitoring and contractions assessed by the nurse touching my abdomen

Continuous external fetal and contraction monitoring

Using a portable monitor (when available) so I can be monitored while up in my room, hallways or if Pitocin is being used. It is important to know that there are some situations in which a portable monitor will not pick up your baby’s heartbeat. In this case, you may need to use the monitor at your bedside.

The method that is recommended by my doctor or midwife for the safety of myself and my baby

Intravenous (IV) Access – We routinely use a continuous IV hooked up to IV fluids. Options you might consider are: (Check all that apply)

Saline Lock – Access into a vein with short tubing and no fluids attached

Continuous IV – Access into a vein with tubing and fluids attached

Pain Management and Comfort Measures – Our goal is to assist you with how you would like to cope with the pain of labor and delivery. Options you might consider are: (Check all that apply)

Walking, squatting and using a birth ball

Labor in water using a shower or tub

Listening to music

Aromatherapy (Scented oils or fresh flowers; please bring your own. No lighted candles.) Keep in mind that some aromatherapy is not to be used for children and may be unsafe for newborns to breathe in.

Wear my own clothes during labor

Massage

Hot and cold packs

Narcotic pain medication given into my IV, if safe for me and my baby

Epidural anesthesia

Labor and give birth without pain medication or epidural anesthesia. Please do not offer me pain medication; I will let you know if I change my mind.

Please list other techniques or methods you have studied:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

My Birth Plan Shawnee MissionHealthBIRTH CENTER

SMH# 68172 02/18

Bag of Water – We may recommend breaking the bag of water based on your situation at the time of labor. Options you might consider are: (Check all that apply)

Allow my bag of water to break on its own

Have my bag of water artificially broken to stimulate labor

Whatever is recommended by my delivery provider for the safety of myself and my baby

Pushing Preferences and Birth – We recommend different pushing techniques based on your situation at the time of labor. Women are usually positioned on the labor bed. Options you might consider are: (Check all that apply)

Directed pushing

Spontaneous pushing

Lying on my side to push

Using the squat bar

Sitting upright in bed

On hands and knees

Cutting the Umbilical Cord – Options that should be discussed with your provider include: (Check all that apply)

Optimal cord clamping which allows the cord to pulsate after the baby is born and may be beneficial in certain circumstances.

Have my labor partner cut the umbilical cord

Have my delivery provider cut the umbilical cord

Cord Blood Collection - SMMC is happy to collect cord blood for any private cord bank when you provide a kit from the company of your choice.

Please arrange for collection of my baby’s cord blood. The private company I will be using is:

___________________________________________________________ (You must bring a kit provided by this company.)

I do not plan to have my baby’s cord blood collected.

Placenta (afterbirth) – SMMC routinely discards your placenta. It may be medically necessary for your placenta to be assessed in the lab. If your placenta does not need to go to the lab, options you might consider are: (Check all that apply)

Have my placenta discarded by the hospital

Keep my placenta for my own private use

Immediate Care of My Baby Following Birth – If your baby is full term (>37 weeks) we routinely place your baby skin to skin on your chest immediately following birth.

Antibiotic Eye Ointment for Baby – We routinely give your baby eye antibiotics within one hour of birth as required by the state of Kansas. Options you might consider are:

Administration of antibiotic eye ointment according to hospital routine

Delay the administration of antibiotic eye ointment for up to one hour after birth

Feeding My Baby – We encourage breastfeeding because it provides optimal nutrition for your baby and supports the health of mom, too. We will assist you with the initial feedings shortly after the birth and throughout your stay. My feeding plans are: _______________________________________________________________

Pacifiers – We only provide pacifiers for comfort during painful procedures.

Circumcision – I plan to:

Have my baby boy circumcised

Not have my baby boy circumcised

Rooming In and Bonding – SMMC supports keeping your baby in your room 24 hours a day. He or she may be taken to our Newborn Observation room if a procedure is needed, however, you or your support person are encouraged to accompany your baby.

Other Things that are Important to Me: