Luminabirth.com

Please check the boxes that you feel passionate about and then create your own plan using the information here. Full Name: __________________________________ Partner’s Name: ____________________________ Today’s Date: ________________________________ Due Date/Induction Date: ____________________ Careprovider’s Name: _________________________ Hospital Name: _____________________________ Ο Other _______________________________________ I’d like these people present before, during and after my birth: Ο Partner ________________________________________________________________________________________ Ο Doula ________________________________________________________________________________________ Ο Partner ________________________________________________________________________________________ Ο Children _______________________________________________________________________________________ Ο Other _________________________________________________________________________________________ Ο Want to discuss birth plan with assigned nurse Ο Return home if labor is less than __ cm. Ο Want a nurse who supports unmedicated birth Ο Walk to room instead of wheel chair assistance During Labor It’s Important To Me To Have: Ο Quiet and respectful surroundings Ο Food/water and juice/ice chips Ο Limited interruptions Ο Labor where and how it feels most comfortable Ο Be free from blood pressure cuff between readings Created, writted and vetted by Lacy Henderson (doula and owner of Lumina Birth) and Barbara Negelow (perinatal nurse and owner of Ready Birth) - May 2012 Ο No induction of labor before 42 weeks gestation Ο Nipple stimulation, sexual intercourse and other natural methods Ο Rupture of membranes Ο Other _______________________________________ Ο Lithotomy position (lying on back in bed) Ο Other _______________________________________ Immediately Following The Birth Of My Baby: Ο Episiotomy performed as a last result Ο Medication only with sufficient fundal massage Ο Hold baby immediately for at least 1 hour Ο Delay newborn procedures for at least 1 hour (i.e. bath, Ο Vitamin K shot done while breastfeeding Ο Eye ointment administered after initial breastfeeding Ο No offering sugar water, pacifier or formula Ο Avoid cleaning of rubbing off of vernix Created, writted and vetted by Lacy Henderson (doula and owner of Lumina Birth) and Barbara Negelow (perinatal nurse and owner of Ready Birth) - May 2012 Ο Partner remain in operating room and recovery room Ο Partner holds baby for mom’s viewing pleasure Ο Partner to remain with baby at ALL times Ο Explain ALL procedures and risks/be communicative of procedures Ο Newborn procedures delayed after initial baby exam for bonding time with dad/mom Ο One arm freed so mom can touch/hold baby Ο Baby brought to mom as soon as possible Ο Skin to skin with dad Ο Doula present for mom and dad’s support Ο No sedatives given to mom that may interfere with alertness for breastfeeding Ο Siblings and/or grandparents welcome Ο No visitors Ο All friends/family welcome Created, writted and vetted by Lacy Henderson (doula and owner of Lumina Birth) and Barbara Negelow (perinatal nurse and owner of Ready Birth) - May 2012

Source: http://www.luminabirth.com/storage/Birth%20Wish%20Checklist.pdf