Birth Plans - Checklist (Page 8 of 8) in pdf

Birth Plans - Checklist Page 8

EPISIOTOMY

I do not want an episiotomy unless there is an

emergency situation

I would like to attempt perineal massage to

stretch the perineum

I would like an episiotomy to reduce risk of

tearin

BABY CARE

I wish to breastfeed exclusively

I wish to breastfeed, but formula

supplementation is acceptable

I wish to formula feed

I would like to meet with a lactation consultant

as soon as possible

I want baby circumcised

I do not want baby circumcised

PRIVACY

I would like baby to “room in”

I am comfortable with male obstetrician

I welcome all well wishers

I wish to limit visitors

I do not wish to have medical students involved

in my care

Other ______________________________________

CESAREAN

In the event that a cesarean section is deemed

necessary, I would like the following:

Partner / spouse present

In the Event that Baby Requires Special Care Due to

Trauma or Illness:

I would like to breastfeed/pump breast milk

Mother’s Signature ____________ Date : _________

Father’s Signature ____________ Date : _________

With a well-considered, well-organized plan in place

you’ll relieve stress by knowing what to expect and by

ensuring that your wishes and preferences are known

to all – including your doctor.

Birth Plans - Checklist Page 8