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Please complete the birth plan form below. A copy will be emailed to you upon completion.
*
Indicates required field
Name
*
First
Last
My preferred pronoun
*
She
He
Other
My birth partner's name and relationship to me
*
I am happy to be photographed during labour by my birth partner and/or photographer/doula
*
Yes
No
Vaginal examinations
*
No exams
In triage / when midwife arrives at home
When I feel the urge to push
As per standard procedure
Offer when care provider feels one would be beneficial
Induction
*
I will wait until to go into labour by myself
I am open to induction for post dates
If any other reasons arise, please discuss with me why induction would be beneficial
Augmentation
*
I would like to allow my body the time it needs to progress by itself
I am open to augmentation. Please discuss with me.
Augmentation through breaking my bags of water
Augmentation with synthetic oxytocin
My GBS status is
*
If GBS positive:
*
I will use antibiotics
I decline antibiotics and would like to do the wait and see approach
I decline antibiotics until membranes have been ruptured for prolonged hours
I decline antibiotics unless there are signs of infection
I would like to use the following for pain relief:
*
a bath / shower
breathing techniques
massage / counter pressure
TENS machine
gas
morphine
fentanyl
epidural
Offering pain medication
*
Yes, please offer if you think it would be a good time to use pain medication
No, please do not offer me pain medication. I will request it if I need it.
My preferred positions to labour in are:
*
Students welcome
*
Yes but only watch
Yes and they may do procedures
No
For fetal monitoring, I prefer
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Doppler (auscultation)
Continuous Electronic Monitoring
Internal monitoring
Pushing (check all that apply)
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I would like to wait until I feel the urge to push
Please tell me when I need to start pushing
I would like to push when it feels right
Be told when to push
I would like to be in the following positions to give birth:
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Hands and knees
On my side
Reclined on my back
Squatting
I would like to decide at the time / keep changing.
When pushing:
*
I would like to tear naturally
I would like an episiotomy
Hands off pushing
Apply hot compress on perineum
Perineum stretching
If stitches are required, please use anesthetic
My partner / myself to catch the baby
Placental delivery
*
Managed third stage (oxytocin shot on thigh, umbilical cord traction)
Physiologic unmanaged third stage (no oxytocin, no cord traction, hands off, no disturbance)
Umbilical cord clamping
*
Wait until after placenta has been birthed
Wait until the cord stops pulsing
Wait 2-3 minutes
Wait until I request for it to be cut
Clamp cord right away
I would like the baby to be:
*
Placed straight into my arms
Wiped first
No hat
With hat
Skin to skin for first hour - please delay newborn exam or perform on my chest
I give consent to the following newborn procedures:
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Antibiotic Eye Ointment
Vitamin K Injection
Vitamin K Oral
Newborn screening
Heart testing
Ear testing
Feeding
*
Breast/chest feeding
Formula
Formula/donated breastmilk supplementation only if medically required - only with my consent
Birth in the Operating Room - Forceps / Caesarean Birth
I would like:
*
My partner present
My doula present
Photography
Please keep conversation focused on the birth
Lower curtain
Cords, wires, IVs on my non dominant hand
Delayed Cord Clamping / Cord Milking
Skin to skin as soon as possible and for as long as possible
Breastfeeding in the OR
Perform newborn tests on my chest
Microbiome introduction
Keep baby with me in recovery
If baby is not able to be with me in recovery, my partner must stay with baby at all times
No milk supplementation with out consent
Any other special requests / things your care team should know about you:
*
Submit
Home
About
Meet Samantha
Client Love
Services
Birth Doula Support
Digital Doula Support
Birth Photography
Sponsor a Birth
Resources
Blog
5 Ways to Discover Your Birth Wisdom
FREE Downloads
Ask the Doulas Video Series
Just for Your Partner
What is a Doula?
>
The Benefits of Hiring a Doula
Let's Chat!