Sample Birth Plan

Patient:   DOB: 

OB: 

Pediatrician: 

Doula: 

Notes:

LATEX SENSITIVE

GBS (+)

BREASTFEEDING

-No saline lock unless medically necessary

-No Cytotec

-No C.R.I.B. procedure

-Intermittent fetal monitoring, no continuous 

-No AROM if possible

-Minimize vaginal exams

-No discussion of pain, I will ask for pain medications or tell a nurse if my pain is not tolerable

-No push coaching

-No episiotomy preferred

-Delayed cord clamping until the placenta stops pulsing 

-Husband to cut the cord

-Deliver placenta naturally, no traction

-No pitocin post delivery if not absolutely necessary, ingest placenta as first option

-No interventions until after first feed with skin on skin contact.  

-Ht, wt, 

-No vit. K injection

-No Hep B vaccine

-No Erythromycin eye ointment

-First bath to be given at home

-Placenta is being used for encapsulation

IN THE EVENT OF A C-SECTION (all applicable points above to be followed as appropriate)

-Husband is to stay with baby at all times

-Baby to mom’s chest ASAP

-Vaginal swab to baby for microbiome

-Exclusive breastfeeding, no formula