My Birth Plan

Date: ____Name: I________want to express my birth wishes to the care givers at Arlington,
VA. Hospital where I have completed childbirth classes I expecting a boy. He will be my
third vaginal childbirth. I am flexible to the decisions of healthcare team that could
make in behalf of my newborn and myself as long I have been informed previously and I
consent.

HUSBAND NAME: _____ DUE DATE: ______INSURANCE #_______MD. NAME (CELL): ________

PREPARATION: I WILL WEAR MY NURSING BRA, GOWN, GLASSES, IV SALINE LOCK ON LEFT FOREARM. I AM SHAVING MY
GENITAL HAIR AT HOME. I PREFER TO WALK AROUND WHEN OUT OF BED WITH PORTABLE INTERMITTENT MONITORING.

As MD discretion, artificial IV induction: ____ If possible no C

section_____ No forceps use_____
Pain management: No narcotics use_____ Epidural IV drip when active
labor, if needed_____ PM

COMFORT LABOR & DELIVERY: FAMILY CENTERED CARE ROOM

Ice chips, clear chicken soup, flavored gelatin, water ___ Coached push,
breathing exercises____
Room w/environment: soft water river sounds___Room temp.73 F__ Vaginal
exams MD___
I want to take a warm shower after my water breaks____ Aromatherapy
lavender scent_______
Episiotomy if necessary ___No pictures, visitors labor and delivery_____
I prefer Squat for delivery___
I authorize in our behalf EBP interventions medically recommended to
preserve our lives____
After childbirth and placenta delivery:
I prefer to hold my baby dried off, skin to skin dry placed matching ID
bands (3) immediately ____
I will donate my baby cord blood____. I would like to eat, have a clean
bed, a warm shower and clean post maternity dress, rest with dim lights
at room_____
I plan exclusively breastfeeding my baby while at my room_____
I want all hospital newborn evaluation and procedures at the first 3
hours after delivery such as: measurements, weight___ Height__ Abnormal
newborn reflex (to be notified) ___ Vit. K___
Hepatitis vaccine___ eye ointment____ babys first bath ____.
Birth certificate before discharge____ I want my baby circumcised at the
hospital _____
Appointments and follow up care for me and newborn instructions verbally
& written_____
I plan exclusively breastfeeding my baby while at my room ____
 After, I want Wi- Fi signal to face time and pray with my mother and take
family pictures____.
signature________ print name _______ witnessed by _______
Date______