My Birth Plan

Shawnee MissionHealthBIRTH CENTER

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 your birth plan and sign below.

Mother’s Doctor/Nurse-Midwife Signature: ________________________________________

Baby’s Doctor Signature:_________________________________________________________

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

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.)

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:

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Bag of Water – We 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 – We routinely let the cord pulsate for 45-90 seconds after baby is born. Options you might consider are: (Check all that apply)

Have my labor partner cut the umbilical cord

Have my delivery provider cut the umbilical cord

Have umbilical cord cutting delayed until it stops pulsating, or up to three minutes (Check with your care provider.)

Cord Blood Collection - Shawnee Mission Medical Center (SMMC) participates in a public cord blood banking donation program and collection kits are available at no cost if you choose to participate. SMMC is also happy to collect cord blood for any private cord bank when you provide a kit from the company of your choice. Options you might consider are:

Donating my baby’s cord blood to the public cord blood banking program (Kits will be provided.)

Arrange for collection of my baby’s cord blood for my own private use. (You must bring a kit provided by this company.) The private company I will be using is: _________________________

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. Options you might consider are: (Check all that apply):

Have my baby placed skin-to-skin on my chest immediately following the birth

Have the nurse clean my baby off first and then placed in my arms or skin-to-skin

Have the nurse clean my baby and evaluate on the warmer before placing in my arms or skin-to-skin

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 and support breastfeeding. Options you might consider are: (Check all that apply)

Initiate breastfeeding shortly after the birth

Exclusively breastfeed my baby on demand

Pump and give my baby breastmilk from a bottle

Bottle-feed my baby with infant formula

o Formula preference:

Similac Enfamil GoodStart

Pacifiers – We only provide pacifiers for painful procedures. Options you might consider are: (Check all that apply)

No use of pacifiers or bottles during the hospital stay

The use of pacifiers for painful procedures only

To allow pacifiers for my baby.

For staff to ask permission before offering a pacifier

Circumcision – I plan to:

Have my baby boy circumcised

Not have my baby boy circumcised

Rooming In and Bonding with My Baby – SMMC supports keeping your baby in your room 24 hours a day. There may be times when your baby will be taken to the nursery for procedures. You are welcome to accompany your baby. Options you might consider are: (Check all that apply)

Have my baby kept with me at night to learn feeding cues

Have my breast-fed baby cared for in the nursery at night and brought to me for feedings

Have my bottle-fed baby cared for in the nursery at night

Transfer my baby to the newborn nursery as recommended by my nurse or provider for the benefit of my own health

Other Things that are Important to Me:

Shawnee MissionHealthBIRTH CENTER

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