Due Date: 10/18/04
Patient of Dr. Peacenick
Scheduled to deliver at North Hawaii Community Hospital.

10/03/04

Dear Dr. Peacenick and the NHCH Staff:

I look forward to sharing my upcoming birth with you.  I have created the following birth plan to help you understand my preferences for my upcoming labor and delivery.  I fully understand that in certain circumstances these guidelines may not be followed, but it is my hope that you will assist me in making this the experience I hope for.  If you have any questions or suggestions, please let me know.

Sincerely,

Bertha Bliss

Labor
I wish to be able to move around and change position at will throughout labor.
I would like to be able to have fluids by mouth throughout the first stage of labor.
I would prefer to avoid an enema and/or shaving of pubic hair.

I would prefer to keep the number of vaginal exams to a minimum.

Monitoring
I do not wish to have continuous fetal monitoring unless it is required by the condition of my daughter.

Labor Augmentation/Induction
I wish to have the amniotic membranes remain intact unless signs of fetal distress require internal monitoring.
I would prefer to be allowed to try changing position and nipple stimulation before pitocin is considered.

Anesthesia
I prefer to birth drug-free. 
     (Custom note regarding use of an epidural).

Cesarean
If my primary care provider determines that a cesarean delivery is indicated, I would like to obtain a second opinion from another physician if time allows.
I would like my husband and doula present at all times if my daughter requires a Cesarean delivery.
I wish to have an epidural for anesthesia.
If my daughter is not in distress, my daughter should be given to Blake immediately after birth.

Episiotomy
I would prefer not to have an episiotomy unless absolutely required for the baby's safety.

Delivery
I would like my husband and/or nurses to support me and my legs as necessary during the pushing stage.
I would like a mirror available so as to have the option of seeing my daughter's head as it crowns.
Even if I am fully dilated, and assuming my daughter is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase.
I would like to have my daughter placed on my stomach/chest immediately after delivery.

After Delivery
I would like to allow the cord to stop pulsating before cutting it.  I would like to cut the cord myself, or have Blake cut it.
I would like to have my daughter examined and bathed in my presence.
If my daughter must be taken from me to receive medical treatment, my husband or some other person I designate will accompany my daughter at all times.  I do not want my baby to have eye treatment, Vit. K shot, or any other medications without my written consent.

I would prefer that my daughter not be bathed immediately, and that my husband or myself give her her first bath.
I would like a private room if available.
After the birth, I would prefer to be given a few moments of privacy to urinate on my own before catheterized is considered.
 

Breastfeeding
Unless medically necessary, I do not wish to have any bottles given to my daughter (including glucose water or plain water).
I do not want my daughter to be given a pacifier.

Photos
I would like to make a video recording of labor and/or the birth.

Other
My support people are my husband and my doula and I would like them to be present during labor and/or delivery.