Canberra Birth Plan Template (Page 2 of 2) in pdf

Canberra Birth Plan Template Page 2

I would like pharmacological pain relief;

Only when I request it

Offered to me by my care providers as required

Never

I would like an episiotomy:

Only as a last resort

If deemed necessary by my

Performed rather than risk a tear

doctor/midwife

Never

During the birth of my baby I would like to:

Push spontaneously

Push as directed

Avoid forceps or vacuum assistance if possible

Be given injection of synthetic oxytocin to help deliver the placenta

After my baby is born I would like:

Skin to skin contact immediately

To keep the placenta

Delay clamping of umbilical cord

To stay with my baby at all times if

possible

My partner to cut the umbilical cord

My partner to stay with baby if I

To keep the cord blood

cannot

I plan to:

Exclusively breastfeed

Feed on demand

Formula feed

Feed on schedule

Combined feeding

I agree to the following medical exams and procedures;

Vitamin K at birth

Newborn Screening test

Hepatitis B vaccine

Newborn Hearing Screen

If my baby is not well, I would like:

My partner and/or I to accompany him/her to NICU or other facility

To breastfeed or provide expressed breastmilk

To hold him/her whenever possible

Be informed and involved in decision making regarding his/her condition

Comments:

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Canberra Birth Plan Template Page 2