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    Hospital Birth Plan

    Uploaded by

    Yuniar Cahyania Intani
    This document outlines a birth plan for a mother giving birth at a hospital. It specifies that the baby is not to receive any circumcision, vaccines, vitamin K shot, or antibiotics unless medically necessary. It requests that the father announce the baby's sex, delay of cord clamping and newborn procedures, skin-to-skin contact, breastfeeding, and no formula or pacifiers. The plan details requests for both a vaginal and cesarean birth, including placental disposal and stitches if a c-section is required.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Hospital Birth Plan

    Uploaded by

    Yuniar Cahyania Intani
    209 views2 pages
    This document outlines a birth plan for a mother giving birth at a hospital. It specifies that the baby is not to receive any circumcision, vaccines, vitamin K shot, or antibiotics unless medically necessary. It requests that the father announce the baby's sex, delay of cord clamping and newborn procedures, skin-to-skin contact, breastfeeding, and no formula or pacifiers. The plan details requests for both a vaginal and cesarean birth, including placental disposal and stitches if a c-section is required.

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    This document outlines a birth plan for a mother giving birth at a hospital. It specifies that the baby is not to receive any circumcision, vaccines, vitamin K shot, or antibiotics unless medically necessary. It requests that the father announce the baby's sex, delay of cord clamping and newborn procedures, skin-to-skin contact, breastfeeding, and no formula or pacifiers. The plan details requests for both a vaginal and cesarean birth, including placental disposal and stitches if a c-section is required.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    209 views2 pages

    Hospital Birth Plan

    Uploaded by

    Yuniar Cahyania Intani
    This document outlines a birth plan for a mother giving birth at a hospital. It specifies that the baby is not to receive any circumcision, vaccines, vitamin K shot, or antibiotics unless medically necessary. It requests that the father announce the baby's sex, delay of cord clamping and newborn procedures, skin-to-skin contact, breastfeeding, and no formula or pacifiers. The plan details requests for both a vaginal and cesarean birth, including placental disposal and stitches if a c-section is required.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    HOSPITAL BIRTH PLAN

    Baby Estimated Delivery Date:


    Mother:
    Father:
    Midwives / Doctor:
    Emergency numbers:
    After birth:

    No circumcision (male or female)

    No Hepatitis B vaccine (we have both been tested negative for Hepatitis B in recent
    blood tests)

    No Vitamin K shot (we will do oral vitamin K with our pediatrician)

    Do not administer antibiotics (I have tested negative for Group B Strep)

    Do not administer Synagis to our child (whether premature or full-term)

    No antibiotic ointment in newborn's eyes (I have tested negative for all sexually
    transmitted diseases)
    If it is medically necessary for me to give birth in a hospital:
    No Electronic Fetal Monitor unless necessary to save my child's life
    I do not wish to receive any induction or pain medication (if you must induce, use Pitocin
    and NOT Cytotec)
    Please do not ask me, in the midst of labor, if I want pain medication, I wish to give birth
    without medication
    Only test my dilation when I am completely comfortable and ready
    Do not clamp the cord until after I have birthed the placenta and the cord has stopped
    pulsing
    Do not suction my child unless it is necessary to save his/her life
    Please let my husband announce the sex of our baby
    Please immediately lay the baby on my chest so I may connect with my baby unless
    unable to do so for the life of the baby please check baby while on my chest (see
    below)
    We will take the placenta and cord home with us for proper disposal/burial
    If it is necessary to save my or my baby's life and I need a cesarean section:
    I would like to have a VBAC after this birth, please use a double stitch when repairing my
    uterine wall and not a single stitch
    Let my husband announce the sex of our baby
    Do not clamp the cord until it stops pulsing
    Do not suction our child unless it is necessary to save his/her life
    Please allow my husband to hold our baby until the placenta has been detached please
    check our baby while in his arms
    Please let me have my baby on my chest after the placenta has been detached and
    delay after-birth procedures (see below)
    We will take the placenta and cord home with us for proper disposal / burial
    After vaginal or cesarean birth:
    Please let us hold our baby and delay washing, weighing, stamping our baby so we can

    be with him/her for those first precious moments


    My blood is NEGATIVE and my husband's POSITIVE. Please test my baby's umbilical
    cord to determine if s/he is a Rh+, to see if I need or do not need Rhogam. (I will request
    the no mercury Rhogam, BayRoh-D, from Bayer Pharmaceuticals.)
    Do NOT give a Hepatitis B shot
    Do NOT give a Vitamin K shot (we will do oral Vitamin K with our pediatrician)
    Do NOT put antibiotic ointment in his/her eyes (Amy has tested negative for all STDs, to
    include gonorrhea and chlamydia)
    We do not consent to any Synagis for our baby
    You MAY give our baby a PKU test after several hours of life, while in my arms (after
    he/she is warm and ready and I may nurse right after)
    Do not wash our baby; I will clean him/her with a damp (NO SOAP) washcloth
    I will be BREASTFEEDING; please do not bottle feed my baby ANY formula or use ANY
    bottle and DO NOT give a pacifier
    Please leave our baby in our room at ALL TIMES
    Please do not let me sleep when my baby is hungry, I would like to exclusively breastfeed
    Do not take our baby out of my room without my or my husband's knowledge and/or
    permission
    Our son will NOT be circumcised; we wish to keep his penis intact

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