Our Family Birth Plan
Name of Mother:
Anticipated Birth Date:
Mother's Support During Labor/Delivery:
M.D. Name:
 
A family birth plan allows parents- to- be the opportunity to plan and anticipate their birth experience. Every effort will be made to honor the requests of parents-to-be throughout the childbirth experience. If the unexpected occurs, rest assured that the MUSC Women and Infant Services Team will work to provide the best care available to the new mother and infant. Should emergency complications arise, components of the birth plan may not be available. We will work to ensure you are informed should this occur.
Labor
  Y/N (Check to indicate yes)
I would like to be free to walk around during early labor.
I wish to be able to move around and change position at will throughout labor.
I will be bringing my own music to play during labor.
I would like the environment to be kept as quiet as possible.
I would like the lights in the room to be kept low during my labor.
I would prefer to keep the number of vaginal exams to a minimum.
Comments:
 
Anesthesia/Pain Medication
(Your nurse and an anesthesiologist will be able to answer question about medication during labor and delivery)
  Y/N (Check to indicate yes)
I would like to be asked if I would like to have narcotic pain relief.
I would like to have a standard epidural.
Comments:
 
Cesaeran
  Y/N (Check to indicate yes)
If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making process.
I would like to (coach) present at all times if the baby requires a Cesarean delivery.
Comments:
 
Epistotomy
  Y/N (Check to indicate yes)
I would prefer not to have an episiotomy unless absolutely required for the baby’s safety.
I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises and perineal massage.
I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch.
If possible, I would like to use perineal massage to help avoid the need for an episiotomy.
Comments:
 
Delivery of Baby
  Y/N (Check to indicate yes)
I would like to be allowed to choose the position in which I give birth, including
I would like    and /or nurses to support me and my legs as necessary during the pushing stage.
I would like to try to deliver in a squatting position, using (coach) or a squatting bar for support.
I would like a mirror available so I can see the baby’s head when it crowns.
Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.
I would appreciate having the room lights turned low for the actual delivery.
I would appreciate having the room as quiet as possible when the baby is born.
I would like to have the baby placed on my stomach/chest immediately after delivery.
Comments:
 
After Delivery of Baby
  Y/N (Check to indicate yes)
I would like to have    cut the cord.
I would like to cut the cord myself.
I would like to hold the baby while I deliver the placenta and any tissue repairs are made.
I would like to hold the baby for at least fifteen minutes before (he/she) is photographed, examined, etc.
I would like to have the baby evaluated and bathed in my presence.
I plan to keep the baby near me following birth and would appreciate if the evaluation of the baby can be done with the baby on my abdomen, with both of us covered by a warm blanket, unless there is an unusual situation.
If the baby must be taken from me to receive medical treatment, (coach) or some other person, I designate will accompany the baby at all times.
I would prefer to hold the baby rather than have (him/her) placed under heat lamps.
I would like to delay the eye medication for the baby until a couple hours after birth.
I would like to bank to umbilical cord blood and have made arrangements to do so.
Comments:
 
Breastfeeding
  Y/N (Check to indicate yes)
I plan to breastfeed the baby and would like to begin nursing very shortly after birth.
Unless medically necessary, I do not wish to have any bottles given to the baby
I do not want the baby to be given a pacifier.
I plan to bottlefeed my baby.
I would like more information about breastfeeding.
I would like more information about breastfeeding.
Comments:
 
Circumcision
  Y/N (Check to indicate yes)
I do not want my son circumcised in the hospital.
I would like to discuss options for pain management during the circumcision.
Comments: