birth.com.au birth plan

This worksheet is designed for the woman, her partner, support person and caregiver to promote discussion and create a clear understanding of your preferences. A lot will depend on your choice of caregiver and where you choose to labour and birth. The birth plan is aimed at clarifying and highlighting the choices that are important to you. Either use this plan by ticking the information that applies to you or create your own plan, using this as a guide. We have also included options for a Caesarean birth.
Our full names...........................................
I / we like to be called...........................................
Our/ my support person's name(s)...........................................
Their relationship to me/us...........................................
Name(s) of sibling(s)...........................................
.
Choice of caregiver, support and birthplace
My chosen caregivers are:
Private midwife
Hospital based midwife
Birth centre midwife
Private obstetrician
Hospital doctors
Local doctor/GP
Shared care by midwife and doctor.
My planned place of birth is:
The hospital delivery suite (name of hospital)
Operating theatre of the hospital
Birth centre
At home
The people who plan to be present at the birth are:
My partner
Friend as support person
Employed support person (doula)
Relative/s
Siblings
The environment I prefer includes:
The lights dimmed.
The room warmed.
No unnecessary conversation.
I'd like to wear my own choice of clothing.
We would like to film (photos and/or video) in the place of birth.
Play music (take ours if not supplied by the hospital).
Candles (check on hospital policy for fire restrictions).
Burning of aromatherapy (check on hospital policy- you may be allowed electric burners).
My own pillow/blankets.
Photos of my child / family / pet, where I can see them.
My partner/support people with me at all times.
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Prelabour and early phase of 1st stage
What I may need during prelabour and early labour while still at home.
For the labour to start of its own accord.
To be allowed to go 10 to 14 days past the due date before being induced.
To avoid augmentation, unless necessary or I request this.
To be reminded "it is the beginning" and to conserve my energy by resting, sleeping if possible, eating and drinking.
Using heat (or cold) packs.
Candles or low lighting.
Music / videos if this feels appropriate.
Phone turned down or off. Put a message "Don't call us we'll call you." on the voicemail.
My partner/support person with me.
Not to let everyone know that prelabour has started, in case it does go for days.
A massage.
Acupuncture or acupressure.
Inflate the pool if birthing at home, fill when labour starts to establish.
Bag packed for hospital, full tank of petrol in the car, baby capsule fitted.
Partner/support person knows best route to hospital and knows where to park.
If my waters break (membranes rupture) and there are no other signs or labour, I would like to wait ...... hrs / days before being induced.
Food and drinks to take to the hospital for myself, partner and or support person.
Comments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Active and transition phases of 1st stage
During the active and transition phases I would prefer:
The freedom to choose positions, use the shower or bath and walk around in labour as desired.
Not to be separated from partner/ support people at any point unless I request it.
The option to return home if I am less than 3cm dilated and all is well.
To wear my own clothes.
To wear a hospital gown.
No students or non-essential personnel to be in the room (a training midwife working with a senior midwife is acceptable).
Not to have internal vaginal examinations unless they are medically necessary or I request them.
Not to have my membranes ruptured unless medically indicated or discussed with us.
Not to be offered managed pain relief, I will ask for it if I need it.
To offer suggestions when I or my partner ask for it.
Not to routinely monitor the baby's heart rate continuously, unless there has been meconium staining or we require further information.
To intermittently monitor the baby's heart rate using a Doppler or Pinard's earpiece (circle one or both).
Providing I and the baby are fine, I would prefer to be free of time limits
Comments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What I may need during this phase from my partner/support person.
To offer me fluids or ice cubes to suck on to keep me hydrated.
To suggest and physically help me into different labour positions.
Walk with me if I need to do this.
Remind me to empty my bladder every 2 to 3 hours.
Emotional support and communication.
Breathe with me when I look lost.
Provide unconditional support even when I appear snappy, unresponsive or am yelling at you!
Remind me to relax between contractions ('body check').
Use key words/affirmations that we have worked out (let go, release, take the breath deeper, drop your jaw etc).
Communicate with the staff for me so I can focus on my labour, unless we need to make decisions about my care.
Not to allow visiting family or friends into the birth room unless I consent.
Not to accept any phone calls from family and friends, we will ring them.
Allow me to have the pain in labour, remember I have my endorphins, if you are uncomfortable try not to show it.
Stay calm.
If I ask for drugs, listen to me so we can talk about the decisions we need to make.
Comments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If possible, I would like to have the following birthing equipment available:
Birthing stool
Bean bags/lots of pillows
Massage implements
Mat
Shower
Bath
Pain management for active and transition phases of 1st stage
I would like to deal with my pain using some or all of the following:
Massage
Touch to reassure me or simply to be close by
Heat / cold packs
Acupressure or acupuncture
Relaxation techniques
Shower and/or bath
TENS machine (may need to hire this)
Breathing techniques
Visualisation
Homoeopathy
Walking with and through contractions.
Communication and feedback, affirmations, eye contact.
I am open to managed pain relief if I request it. Do not offer it to me. If requested I would prefer:
Gas
Narcotic injection (Pethidine)
Epidural/spinal/combined (circle one)
I do not have any preferences about pain relief, I would prefer to make my decisions as I labour
An internal vaginal examination prior to any managed pain relief, to help me make my decision.
Comments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2nd stage of labour and the birth
I would prefer the following for the birthing phase:
Squatting
On all fours (hands and knees)
Standing
Side-lying position
Semi-reclining
I do not wish to lie on my back
Whatever position feels right for me at that time
I do not wish to be encouraged into another position that suits the caregiver.
I want to push instinctively (not coached or told when to push)
I wish to have the options of:
Being in the shower
Being in the bath - water birth (check your birthplace's policy).
Sitting on a birth stool or toilet
Being allowed to rest and wait if I do not have the urge to push straight away, providing the baby and I are fine.
Viewing the birth by using a mirror
Touching my baby's head as it crowns.
The option of my partner 'catching' the baby.
Risking a tear rather than have an episiotomy (unless a medical emergency)
To have an episitiomy. Reason being....................................................................
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If induction or augmentation becomes necessary I would prefer one or a combination of:
A Foley's catheter inserted
Prostaglandin gel or pessary
Having my waters broken
Having a Syntocinon drip
Having a combination of these if necessary.
If an assisted birth becomes necessary I would prefer if possible to have:
Forceps.
The use of a ventouse (vacuum).
Caesarean birth
Depending on the medical circumstances, I would prefer to have:
An epidural
A spinal
A general anaesthetic
My partner present if an epidural or spinal is used.
My partner/support person close by if a general anaesthetic is used.
My child(ren) to wait with our support person (name and relationship to you) in the ward before and/or after the Caesarean operation.
The sterile screen lowered so I can see my baby being born (epidural or spinal only).
A running commentary of the operation to let me know what is happening.
My partner to engage me in conversation so I am distracted.
A walkman to listen to, to relax me during the procedure.
The placenta delivered by controlled cord traction rather than manually removed, to reduce bleeding and infection risks.
Our baby given to me or my partner as soon as possible.
Photos taken in the operating theatre.
A videotape of the the birth of our child.
My baby stay with me until the suturing is finished.
My partner and baby to wait for me in recovery.
The opportunity to try and breastfeed my baby in recovery.
Or be taken to the intensive care nursery (if applicable) after leaving recovery to see my baby.
My baby's cord blood donated (if available).
My placenta kept for me to look at (when convenient).
My placenta kept so I can take it home.
Comments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Birth and soon after
Presuming my baby is well I would prefer:
To hold my baby immediately after the birth.
To wait until the umbilical cord stops pulsating before its cut and clamped.
My partner to cut the cord.
To discover the sex of my own baby and not be told by others.
Skin to skin contact with my baby.
Not to have my baby's nose and mouth suctioned unless it is necessary (e.g. meconium in the amniotic fluid).
To contribute to the cord blood donor scheme (if available).
To avoid the Syntocinon injection unless necessary.
To have Syntocinon to help control the bleeding and deliver the placenta.
To be shown my placenta after the birth.
To keep my placenta.
All the newborn procedures (weighing and measuring) to wait until I have had time to be with and/or breastfeed my baby.
My baby to have a vitamin K injection / 3 oral doses (circle one).
Not to give my baby vitamin K (unless necessary).
All newborn procedures to be carried out in my presence.
Not to have my baby washed with antiseptic solutions.
My partner to stay with the baby at all times, if I can't be with my baby.
To have my stitches attended to soon after the birth (if required).
To wait until after I have fed my baby and settled before having stitches (if required).
A heat pack for any after pains/ analgesic medications as recommended, if required.
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Postnatal days
I would prefer to:
Breastfeed my baby.
Bottle feed my baby.
Breast and bottle feed my baby.
Room in with my baby.
Go home early and have midwives visit me at home.
My partner to room in with me on the postnatal ward (if possible).
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