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 Missio n Health BIRTH CENTER