SOPHOS DOULAS

Name:
Date of birth:
Partner:
Doula:
Caregiver:

Birth involves lots of surprises, and because of this, it is important to establish which options you desire or are open to as the experience unfolds. The Birth Plan is intended to be a flexible guide for how you envision your birth—you may change your mind at any given moment, and we understand that. This plan is intended to be an aid to you, your partner, doula, and caregiver so that we may honor and remind you of your first intentions.

BELOW IS A SAMPLE BIRTH PLAN

Beginning of labor

• I would like labor to begin naturally, even if I pass my due date.  If my bag of waters breaks first, I would like to wait for contractions to begin on their own.
• I want to spend as much time at home as possible before I go to the hospital.

People in the room

• I request that no residents or students be present during my labor.
• I would like my partner and our doula to be present for labor and delivery.

First-Stage Labor

• I would love to use water during labor to ease pain (bathtub or shower).
• I would like to try to go through the process of labor and deliver without any pain medication.  If needed, I would like to talk to my partner and doula before receiving any.
• I request that the hospital staff suggest natural ways to manage pain (massage, changing position, walking).
• I would like as little interruptions and vaginal exams as possible.
• would like augmentation performed only if baby is in distress.

Second-Stage Labor

• I would rather risk a tear than have an episiotomy.
• I would like a squat bar to help me push.
• I would like to be able to see my baby or touch my baby's head as they are crowning.

Cesarean Section

• I strongly hope to avoid a cesarean.
• If a cesarean becomes necessary, I would like my partner to be present at all times.
• I would like to be conscious during the procedure.
• I would like to hold or touch my baby immediately afterwards, before examination.

Post-Birth

• I would like to hold and do skin to skin contact immediately after birth.
• I would like the staff to wait until the umbilical cord stops pulsating before clamping it.
• I would like my partner to cut the umbilical cord.
• I do not want routine Pitocin postpartum.
• I would like to postpone routine newborn procedures for as long as possible (1 hour), until after I have held and breastfed my baby for the first time.
• I would like all newborn procedures to take place in my presence, while I or my partner is touching the baby.
• I plan to breastfeed.
• I DO NOT want my baby to be circumcised if he is a boy.
• I DO want to keep the placenta and will bring a special container (Cooler) for it.

AUGMENTATION:

• I would like an epidural to help relax if I am not making progress with dilation.
• I would like to try Pitocin to help with contractions if the epidural slows down my contractions.
• I would like to try attempt all possible options before opting for a cesarean.

Additional questions:

Are you video-taping the birth? If so, who will be in charge of this—partner? doula? family member?

Is there anything special we should be aware of such as religious observances, spousal issues, sibling needs, etc/

What are some things that you DO NOT want for your labor and birth?

What are your main fears surrounding labor and birth?