30 Jan Writing a Birth Plan
A Sample Birth Plan
Name: Sally Jane
Date of Birth: January 1, 1988
No Known Diagnosed Allergies
Husband: Brian Jane
OB-GYN: Dr. Amanda Smith
Expected Due Date (EDD): 04/04/2019
Current Medications: Prenatal Vitamins
Blood Type: O-; Received RhoGAM(1) on 02/01/2019
No previous surgeries
Preterm Labor during 26th week of current pregnancy; no medications given
Received a flu shot on 10/28/2018
Support Team at Birth: Husband Joe; Nurse Doula Stefanie; Mother Jane
I do not want any other visitors in my room while I’m laboring.
I am choosing to labor naturally with no pain medications.
I would like to have a telemetry monitor so I can walk freely throughout labor unit.
I do not mind having an IV while in labor.
I would like my husband to cut the umbilical cord.
I’d like to tear naturally, avoiding an episiotomy unless medically necessary.
We are delaying cord clamping.
As long as baby is healthy, I would like her placed directly on my chest for skin-to-skin.
I wish to breastfeed; DO NOT introduce a pacifier to my child.
My baby’s pediatrician is Dr. Evan Miller at Pediatrics of OC
I do not know my baby’s gender. If I deliver a son, I would like him to be circumcised.
I will be doing cord blood collection with StemCyte; collection box provided.
I have no opposition to the vaccinations given to our baby once delivered.
Eye ointment can be applied when necessary by medical staff upon delivery of infant.
Part of my services is guiding my families in greater detail on how to compose an individualized birth plan. If you are interested in learning more about these services, please feel free to reach me. I’d love to help you through this journey!
All information from this birth plan is not based on a real individuals. All dates, doctor’s names, and facilities have been fabricated for teaching purposes.
1. “RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood.” (Retrieved from http://www.rhogam.com/patients/about-rhogam/)
2. “Group B Streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman’s vagina or rectum.” (Retrieved from http://americanpregnancy.org/pregnancy-complications/group-b-strep-infection/)
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