Example of Hospital Birth Plan {free printable!}

Example of Hospital Birth Plan

This is the Birth Plan that I wrote up for if I needed to be transferred to the hospital during my planned home birth.  I acknowledge that most births are not medical emergencies, but some can become that, so I wanted to be well-prepared.

These were my wishes, based on my own intensified research, but you can of course edit it to suit your wishes!  I hope it helps you!

The following is included: Hospital Birth Plan (Editable!)

HOSPITAL BIRTH PLAN

Baby Estimated Delivery Date:

Mother:

Father:

Midwives / Doctor:

Emergency numbers:

After birth:

• No circumcision (male or female)

• No Hepatitis B vaccine (we have both been tested negative for Hepatitis B in recent blood tests)

• No Vitamin K shot (we will do oral vitamin K with our pediatrician)

• Do not administer antibiotics (I have tested negative for Group B Strep)

• Do not administer Synagis to our child (whether premature or full-term)

• No antibiotic ointment in newborn’s eyes (I have tested negative for all sexually transmitted diseases)

If it is medically necessary for me to give birth in a hospital:

• No Electronic Fetal Monitor unless necessary to save my child’s life

• I do not wish to receive any induction or pain medication (if you must induce, use Pitocin and NOT Cytotec)

• Please do not ask me, in the midst of labor, if I want pain medication, I wish to give birth without medication

• Only test my dilation when I am completely comfortable and ready

• Do not clamp the cord until after I have birthed the placenta and the cord has stopped pulsing

• Do not suction my child unless it is necessary to save his/her life

• Please let my husband announce the sex of our baby

• Please immediately lay the baby on my chest so I may connect with my baby unless unable to do so for the life of the baby – please check baby while on my chest (see below)

• We will take the placenta and cord home with us for proper disposal/burial

If it is necessary to save my or my baby’s life and I need a cesarean section:

• I would like to have a VBAC after this birth, please use a double stitch when repairing my uterine wall and not a single stitch

• Let my husband announce the sex of our baby

• Do not clamp the cord until it stops pulsing

• Do not suction our child unless it is necessary to save his/her life

• Please allow my husband to hold our baby until the placenta has been detached – please check our baby while in his arms

• Please let me have my baby on my chest after the placenta has been detached and delay after-birth procedures (see below)

• We will take the placenta and cord home with us for proper disposal / burial

After vaginal or cesarean birth:

• Please let us hold our baby and delay washing, weighing, stamping our baby so we can be with him/her for those first precious moments

• My blood is NEGATIVE and my husband’s POSITIVE. Please test my baby’s umbilical cord to determine if s/he is a Rh+, to see if I need or do not need Rhogam. (I will request the no mercury Rhogam, BayRoh-D, from Bayer Pharmaceuticals.)

• Do NOT give a Hepatitis B shot

• Do NOT give a Vitamin K shot (we will do oral Vitamin K with our pediatrician)

• Do NOT put antibiotic ointment in his/her eyes (Amy has tested negative for all STDs, to include gonorrhea and chlamydia)

• We do not consent to any Synagis for our baby

• You MAY give our baby a PKU test after several hours of life, while in my arms (after he/she is warm and ready and I may nurse right after)

• Do not wash our baby; I will clean him/her with a damp (NO SOAP) washcloth

• I will be BREASTFEEDING; please do not bottle feed my baby ANY formula or use ANY bottle and DO NOT give a pacifier

• Please leave our baby in our room at ALL TIMES

• Please do not let me sleep when my baby is hungry, I would like to exclusively breastfeed

• Do not take our baby out of my room without my or my husband’s knowledge and/or permission

• Our son will NOT be circumcised; we wish to keep his penis intact