Birth Plan (including informed consents and refusals)

October, 2010
Mother:
Father:
Infant to be named:

Introduction

Thank you for taking the time to review this document. This is an addendum to any
informed consent we have signed with you. In the case of a conflict, this document prevails.
We have used mandatory language to express legal consents and refusals. In the absence
of mandatory language, you may treat a request as a preference.

We have taken steps to ensure a vaginal delivery including dietary management to reduce
risk of recurring preeclampsia, routine prenatal care, exercise, use of raspberry leaf tea,
study of evidence based practices and staying at home as long as possible.

We have elected to labor at home until such time as transfer to the _____________, in our
judgment and taking into account the risks associated with our situation, is warranted. We
expect to be treated with dignity and recognition that we did not undertake any of our
choices lightly or in the absence of careful consideration. In exchange we will work with you
as partners in the birth process.

We are well-informed about many of the risks relevant to our birthing circumstances and are
active decision makers regarding prenatal care, labor, delivery, postpartum care, and
antenatal care. We expect to receive detailed information about relative risks and benefits
of procedures, medications, or interventions you advise.

When briefing us, please advise us on the desired effect of the procedure, medication, or
intervention, the probability of success, the risks if it fails, the other options (including doing
nothing), and what options will be foreclosed if we proceed and the procedure, medication or
intervention is not successful.

We are unlikely to consent if we feel we have not been fully briefed on the risks and
benefits. If you fail to consult with us, consent is refused, unless otherwise given in this
document or consistent with the guiding principle set forth below. We recognize that some
refusals may present medical, ethical, or legal challenges for you. If you ask we will sign a
statement specific to the procedure, medication or intervention at issue that we have been
given advice and have chosen to act against that medical advice. We hope this will be a
collaborative effort, but are prepared to assert our legal rights if necessary.

Guiding Principle

In any case in which my health and my son’s health are in conflict, we want to be informed
of the relative risks of the available options to both mother and fetus, including the risk of
doing nothing.
Participants

Health Care Power of Attorney. _____ is my health care power of attorney and shall make
decisions for me in the event of incapacitation.

Birth Advocates: I will have as birth advocates ____ and ______. They will be present
throughout labor, birth, and initial hours postpartum.

Medical Staff: We would like to keep the birth team to a minimum necessary. We will allow
non-essential observers if we select an option that is non-standard in the interest of
increasing awareness of alternatives. We reserve the right to ask that any person we find to
be disruptive or distracting removed from the room.

Family & Friends: It is our desire that my husband, ____, be present during birth. The
following family members may be present: _____(my mother), _____ (________), and _______
(friend). The decision to exclude any of these persons rests in our sole discretion. All other
family and friends must wait outside until we invited them in. Please hold calls until after our
son has had his first nursing session.

Infant Care

Antenatal Care: Regardless of the nature of her birth (natural or surgical), our son shall be
immediately placed on my body upon birth skin to skin (a blanket may placed over her).
Antenatal procedures, including blood tests, shall be conducted while he is in arms. We
intend to provide “kangaroo-style” skin-to-skin care for him during our hospital stay.

• Do not wash him.

• No suction unless medically necessary.
• Eye drops shall not be administered.
• Please delay cord cutting as long as Cord continues to pulse. We do not want
immediate cutting of the cord. My husband would like to cut the cord if possible.
• We refuse the following procedures and medications:
o No vaccinations. These shall be administered by her pediatrician.
o No SSN application info shall be submitted
• I would like to delay the administration of vitamin K up to 2 hours after birth unless
medically necessary.
• I would like only the orally administered vitamin K to be given to our baby.

Room In: Our Son shall room with me and shall not be removed from the room unless she
requires medical treatment that cannot be provided in room.

Parental Involvement in Medical Care: A parent shall hold our son for all procedures and
examinations and a parent shall be consulted before any procedure is performed on our son.

Feeding: No formula or glucose water. Our son will be exclusively breastfed for the first six
months of life. He shall be given to me as soon as possible for the purpose of nursing,
including immediately upon gaining consciousness after a cesarean under general
anesthesia.
 • Terminal Condition or Severe Damage: If the circumstances of his birth are such that
he is severely brain damaged or has a condition incompatible with life, we expect to
decline lifesaving treatment for him. Do not administer life saving treatment in such
a case without our express consent. Routine CPR after birth is permissible and does
not require express consent—although we may elect to terminate CPR if the
circumstances warrant. We will want to hold him so we may provide love and
comfort in him dying.

Labor and Birth

Envirionment

• I prefer to have ____ with me at all times

• I prefer to give birth in a birthing room with a shower and/or bath
• I prefer the following equipment be available
o Birthing bed
o Birthing Ball
o Birthing Tub/pool/shower
o Birthing Stool
o Squatting Bar
• I would like to play music
• I would like to have a TV available

Anesthesia and Analgesics. Do not administer any anesthesia or analgesics except to stitch
vaginal tears or cuts (use local). I intend to use breathing, meditation, warm water, and
baths to ease discomfort. We will bring music and wish to have the lights at a level that I
find comfortable. Do not administer any narcotic without thorough review with me
of the full range of possible side effects and the relative risks and benefits of the
drug.

Other Medications:

• Do not administer sulfa drugs.

• Pitocin shall not be administered during labor because of the risk of uterine
rupture. I intend to allow labor to progress at a natural pace. I do not consent to
augmentation. Pitocin may be administered postpartum to reduce the risk of
hemorrhage.

No AROM and Stripping of Membranes. I do not consent to stripping of membranes or

artificial rupture of the amniotic membrane in advance and require specific
consultation before either procedure is performed. Labor shall be allowed to start
spontaneously in the absence of a medical emergency. I have higher than average amniotic
fluid levels. We have discussed with our prenatal care provider what to do in the event of a
gushing rupture of amniotic fluid. If I agree to rupture of the membranes, it shall be with a
small pinprick and only if the baby is head down and applying pressure to ensure the fluid
leaks out slowly and not in a rush.

Vaginal Examinations.

• I prefer to have minimal internal exams

• During a Vaginal Exam, I prefer at no time to have my membranes broken
unless there is an emergency situation
 • If I am less than five centimeters dilated, I would like the option of going
home.
• If I am less than five centimeters dilated and my water has broken, I would
like the option of returning home.

Induction

• If induction becomes necessary, I would like to try natural induction

techniques first (with the guidance of my practitioner)

Natural Induction Techniques Include:

• Breast Stimulation
• Walking
• Enema
• Sexual Intercourse
• Chiropractic

Fetal Monitoring. We refuse continuous electronic fetal monitoring. We agree to an

initial period of external fetal monitoring upon first arriving at the hospital. Subsequent
monitoring shall be intermittent. We are familiar with the studies that show that remote
electronic fetal monitoring does not improve outcomes and we request use of a Doppler
rather than monitoring strips for as much of labor as possible. I intend to move around
and reserve the right to remove monitoring strips if they interfere with movement or comfort
measures.

IV and Food. I do not want an IV unless I become dehydrated. Upon consultation, I may
agree to a hep lock if circumstances warrant. I intend to take fluids and eat snacks at my
discretion. I understand the risk of aspiration should an emergency cesarean under general
anesthesia be required.

Positions. I will try recommended positions and reserve the right to refuse to assume or
sustain a particular position if it does not feel right. I plan to have a warm water birth in a
bath.

No Episiotomy. I wish to have my perineum supported during crowning to minimize tearing.

If your staff is not familiar with the technique, one of my labor support people or my
husband shall provide such support.

No Catheter. No catheter during labor. I will walk to the bathroom.

Placenta. The placenta shall be allowed birth spontaneously in the absence of a medical
emergency. Do not attempt to manually remove it without consent. We want to see the
placenta and reserve the right to take it home with us if we so choose.

Clothing and Vocalization. I will bring my own clothing and may choose to be undressed
during labor and birth. I ask that the only time you suggest I might want to cover up is after
the baby is born for pictures. I reserve the right to remain topless in my room postpartum to
encourage breastfeeding. I expect I may vocalize during labor and have no intention of
moderating or lowering my voice if I do so.

Cesarean Delivery
• I, or ____, shall be the ultimate decision maker with respect to whether a cesarean is
warranted.
• Unless an emergency, confirm any abnormal fetal heartbeat with fetal scalp blood
oxygen readings.
• Use spinal anesthesia unless an emergency.
• Use double layer suturing as I will attempt a VBAC in my next pregnancy.
• Consult with me regarding all medications to be administered.
• ____ will be present during all portions of the surgery.
• I intend to hold our son immediately. My hands shall be left unstrapped. Hand our
baby to ____ immediately on extraction and he will help me hold him (please offer
him a blanket for him). After a few minutes he will carry him to the warmer for his
initial check. If in your medical judgment there is an immediate need for more
intensive care—you must obtain ___’s consent before deviating from the plan
described in this paragraph.
• Our child shall not be taken to the NICU without our consent. We intend to provide
massage stimulation and skin to skin contact as a first line of assistance for any post-
cesarean breathing difficulties our son may encounter.
• ____ shall accompany our son for any care and shall make her medical care decisions,
unless he agrees otherwise under the circumstances.
• If ___ departs leaves the OR with our son, I would like one of my other labor support
personnel to be at my side. If ____is not in the room for an emergency cesarean
under general anesthesia, bring him to the location where our son is being cared for
promptly.
• In the event of a uterine rupture or any other complication impairing the integrity of
my uterus, I want you take measures to repair, rather than remove, my uterus. You
must have specific consent from myself or my husband to perform a hysterectomy.