Worksheet Template For Preparing Your Birth Plan With Samples (Page 14 of 14) in pdf

Pregnancy, Childbirth, and the Newborn

Cesarean Birth Plan

Birth Preferences for Grace Miller

I am a single mother by choice. My sister Alex and my friend Jacob (who is an experienced surgical nurse)

will be providing support for me during my birth.

Although I had hoped for an unmedicated vaginal birth, my baby is in the breech position and has resisted

turning, despite my having tried acupuncture and a variety of self-help methods to turn her. Thus, I will be

having a cesarean delivery as soon as my labor has begun on its own. I still hope to maintain as much close-

ness and intimacy with the birth process and my new baby as possible under these circumstances.

I have consulted with my OB and with hospital anesthesiology staff in advance and was told that the proce-

dures I make below are typically possible, assuming all is well with me and baby.

MY PREFERENCES

•

I would like my sister and friend to accompany me into the OR. I realize that it is not standard policy

to have two support people; however, due to my extreme anxiety around a C-section, I believe it would

help me to have one person to go with the baby if need arises and one person to stay with me and keep

me calm. We understand that in the event of an emergency, one or both of my support people could be

asked to leave, and we trust the OR staff’s judgment in this matter.

•

I would like the IV, blood pressure cuff and pulse oximeter to be positioned on my left side so my right

hand (my dominant hand) is free to hold my baby, and the electrocardiogram (ECG) leads placed on

my back so my baby can be placed for skin to skin after delivery.

•

I would like my baby to be delivered through the incision slowly, as described in “The Natural

Cesarean: A Woman-Centred Technique” by J. Smith ( ). The head is lifted

out, but the trunk remains in utero for a few minutes, while baby begins to breathe on her own.

•

I would like the cord clamping and cutting to be delayed as long as possible, preferably until it has

stopped pulsing. If delayed cord clamping is not possible, I request milking of the cord (gentle pressure

applied to the umbilical cord from placenta to baby) to push the cord blood into the baby before the

cord is clamped and cut. This should be done three times in ten seconds for best results.

•

I request that my internal organs be left inside my body for the duration of the surgery (i.e., please do

internal repair).

•

I would like the baby to be brought immediately to my chest for skin-to-skin contact and nursing while

my surgery is repaired. My sister and/or friend can help secure the baby on my chest if necessary. I

would like us to both be covered in warm towels to maintain temperature rather than a trip to the

warming table and swaddling. In the event that this is not possible, we request that the baby be brought

immediately to my sister’s chest for skin-to-skin contact.

•

Apgar, labeling, and drying may be done on my chest. I would like to delay any routine medications or

tests (vitamin K, eye drops, blood tests) one to two hours and until nursing is initiated.

•

I request my incisions be repaired with double layer sutures and my medical records document this type

of repair.

•

Once we are ready to move to recovery, I request that the baby ride on my chest to the recovery room.

If that is not possible, I wish my sister to go with the baby and to reestablish skin-to-skin contact as

soon as possible.

Worksheet Template For Preparing Your Birth Plan With Samples Page 14

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