Date post: | 13-Jul-2018 |
Category: |
Documents |
Upload: | truonglien |
View: | 214 times |
Download: | 0 times |
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: