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Onslow. Memorial Hospital

Birth Plan

Thank you for choosing Onslow Memorial Hospital to deliver your baby! This is an exciting time for you and your family, and we are happy to be a part of it. In order to better understand your wishes for your labor experience, please fill out the following birth plan. You may print it and bring it with you, or we can print it when you arrive.

What is your Birth Plan? »

*Name: 

*Email: 

*Expected Date of Delivery: 

My main support person will be:
 Significant other
 Family member
 Friend: 
 Does not apply

Additionally, I would like the following people present for labor support:
 1: 
 2:  

I would like the atmosphere and environment in my labor room to be:
 Calm, quiet, dark
 Happy, bright, lively
 Does not apply

During labor, I prefer:
 To remain in bed
 To move around as much as possible, provided that continuous monitoring is not necessary
 Does not apply

Regarding pain medications/epidural, I prefer that the nurse/provider:
 Offer/suggest pain meds
 Wait until I ask for them
 Does not apply

Labor Support Methods I plan to use: (check all that apply):
 Massage
 Hot/cold packs
 Positioning
 Labor imagery
 Hypnosis
 Relaxation
 Breathing exercises
 Medications
 Epidural
 Birthing Ball
 Rocking Chair
 Doula
 Labor Squat Bar

Regarding pushing, I prefer:
 To push when my body tells me to push
 Active coaching to push
 Does not apply

Immediately following the birth (if vaginal), provided the baby and I are both stable, I would like:
 The baby to be placed on me for immediate skin-to-skin contact
 The baby to go to the warmer and be cleaned before I hold him/her
If I am unable to hold my baby immediately after delivery, I would like for my primary support person to provide skin-to-skin contact with my baby
 Does not apply

My support person would like to cut the umbilical cord if the baby is stable:
 Yes
 No
 Does not apply

I plan to feed my baby by:
 Breast
 Bottle
 Both
 Does not apply

I would like to breast-feed my baby as soon as possible after delivery, as recommended by the American Academy of Pediatrics:
 Yes
 No
 Does not apply

It is okay for my baby to have a pacifier:
 Yes
 No
 Does not apply

If I have a baby boy, I would like for him to be circumcised:
 Yes
 No
 Does not apply

Additionally, I would like the following if possible. (Please list any cultural practices or desires that have not been previously addressed.)


Labor can be a very unpredictable process. While the staff at Onslow Memorial Hospital will do everything possible to honor the above birth plan, I understand that circumstances may prevent parts of this plan from being honored.

* Required  

 

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5/23/12
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