NEIGHBORH a. Z OD BIRTH CENTER BIRTH PLAN Name: Background: Support person: © Doula: Healthcare proxy signed? Cord blood bank plan For pain management | would lik Please don't ask, | will let you know _| Unmedicated \V pain medications Nitrous Oxide Epidural Undecided During birth I would like: Choose: push spontaneously/ directed A mirror when | push My support person to help catch (if possible) Delayed cord clamping Informed discussion if an episiotomy, forceps or vacuum is recommended If Ineed a Cesarean Section, | would like My support person in the Operating Room “Clear drape at time of birth Delayed cord clamping Skin to skin in the operating room Due Date: Ihave: Group B Streptococcus 1) Elevated blood pressures Gestational diabetes Other: During labor | would like: Choose: IV placement/ none Intermittent fetal monitoring Limited hospital staff Few cervical exams Free movement Get in the shower or tub After birth I would like: Skin to skin immediately for ct least | hour Partner will cut umbilical cord Deliver placenta without pulling Lactation Consult Choose: rooming in/ nursery For my baby I would like: Thour before baby receives meds Choose: breast/ bottle/ both No pacifier/artificial nipple Delayed bath Choose: Hep. B/Vit. K./Erythromycin Ifa boy, circumcised (yes/no)NEIGHBORH@OD BIRTH CENTER BIRTH PLAN Name: Due Date: About Me: Hopes & Wishes: Additional Information:HOSPITAL BAG CHECK a Identification Insurance card Health care proxy form Birth plan Labor outfits (2-4) Postpartum outfits (2-4) Underwear Socks Slippers Headscarf Hospital will have: hospital gown, mesh underwear Toothbrush/Toothpaste Face lotion Body lotion Deodorant Face soap Body soap Shampoo Conditioner Hospital will have: sanitary pads Breast pump Nursing bra Nipple cream Breast pads Car seat Outfit for your baby to go home in Hospital will have: Pump (at the hospital), diapers, swaddle blankets Phone charger Laptop charger Watch charger Speaker and charger Battery operated tea lights Laptop/ DVD ployer Games