Baby Birth Plan


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If my doctor or midwife believes induction is necessary, I would prefer the following: Options to help prepare my cervix (also referred to as cervical ripening): Cervical ripening vaginal insert If I need a C-section and it’s not an emergency: If possible, I’d like to have a moment alone/with my partner/ family/other to process this before having a C-section Pill (misoprostol/Cytotec®) not FDA approved I’d like to have __________________ present for the procedure Catheter Other: I’d like to have a sheer screen to watch, if possible I’d like to have it explained as it happens I’d like to have music playing Options to help with contractions: IV drip (oxytocin/Pitocin®) In case of interventions such as vacuum, forceps or episiotomy, what requests can I make Nipple stimulation Walking around My doctor or midwife will help break my water If I need any of these procedures, please discuss with me beforehand I would prefer not to have an episiotomy unless medically necessary I would prefer not to have forceps used I would prefer not to have a vacuum used After-delivery preferences: Procedure for the umbilical cord: Use of the placenta: My partner (or ______________________ ) to cut the cord Hospital to take Delayed clamping and cutting of the cord (after it stops pulsating) Take home (there may be additional steps taken by the hospital for the release of your placenta) Send it to the cord blood bank I want the placenta collected for banking Company name Company name Blood Cord Both I want to hold my baby for the first time: Immediately after delivery (skin to skin) If my baby is a boy: After being wiped clean I want my baby circumcised prior to leaving the hospital After weighing and initially cleaning my baby I do not want my baby circumcised prior to leaving the hospital I’d prefer not to hold my baby after childbirth Other: I want to feed my baby with: I want to start breastfeeding: Breast milk I prefer my baby doesn’t get any bottles 2 As soon as possible after deliver


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