Birth Plan - St. Clare Hospital

Environment:Birth PlanSt. Clare Hospital and Health ServicesChildbirth Center___ Dim lights___ Peace and quiet___ Music___ Wear my own clothes___ No students, residents___ Minimal vaginal exams___ Other _____________________________Mobility:___ Maintain mobility (walking, rocking, birthingball, up to bathroom, etc.)___ Mobility not important to me___ Other ____________________________Hydration:___ No restrictions___ Clear fluids___ Ice chips___ IV (only if problems with labor or medicationsneeded/requested)Monitoring:Intermittent___ Doppler___ External Electronic Monitor

Continuous___ External Electronic Monitor___ Internal Electronic MonitorPain Relief Offers:___ Only if I ask___ Offer if uncomfortable___ Offer as soon as possible___ Other _______________________________Pain Relief Options:Non medicinal:___ Relaxation___ Breathing techniques___ Positioning___ Distraction___ Water (shower or whirlpool)___ Heat or cold therapy___ Massage___ Aromatherapy___ AcupressureMedicinal:___ IV medication (Fentanyl)___ Intrathecal___ EpiduralPushing:___Choice of positions___ Spontaneous bearing down (listening to my bodyand pushing)___ Directed pushing (being told when to push)___ Prefer to use people for leg support (avoidfoot pedals)___ Foot pedals___ Squat bar___ Watch my birth using a mirror___ Touch my baby’s head as it crowns___ I’d like to hold my baby on my chest rightafter birth

Cesarean Section:___ Avoid cesarean section if at all possible___If a cesarean section is necessary,partner/coach with me at all times during surgery___General anesthesia in an emergency only___ Spinal anesthesia, if possible, so I can beawake during the delivery___ I’d like to be first to hold the baby___ I’d like my baby to be given to mypartner/coach after the birth___If circumstances permit, I’d like to breastfeedmy baby immediately after the birthEpisiotomy:___ I prefer no episiotomy unless absolutelynecessaryCord Cutting:___ Mom to cut cord___ Partner to cut cord___ Doctor to cut cordFeeding Baby:___ Breastfeeding as soon as possible___ Bottle feeding___ No pacifiers or bottles (for breast fed babies)Separation:___ None (baby to be weighed and given Vitamin Kand eye medications when I ask)___ Delayed (baby to have above afterbonding/breastfeeding)___ Rooming in (baby not to be in the nursery)

___ Partial rooming in (baby in nursery when I/mypartner are sleeping or not in my room)Circumcision:___ Yes___ NoSignature:________________________________________________