Mercy Birth Plan
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My Mercy Birth Plan Expectant Mother’s Name Birthdate Expectant Mother’s Physician Baby’s Physician Baby’s Due Date My Labor Support Team • I plan to have the following people with me during my labor and birth: PartnerRelationship Doula Other visitorRelationship Other visitorRelationship Other visitorRelationship Comfort Measures • I plan to try these additional comfort measures (check all that are desired): Walking, squatting and using a birth ball Labor in water using a shower or tub Listening to music (please bring your own) Massage Aromatherapy (scented oils, fresh flowersplease bring your own) ¨ Wear my own clothes during labor (hospital gowns are also available) ¨ ¨ ¨ ¨ ¨ Monitoring My Contractions and Baby’s Heart Rate • I would prefer (check all that apply): ¨ Checking on the well-being of my baby using intermittent monitoring ¨ Continuous electronic monitoring placed with elastic belts around my abdomen ¨ Using a telemetry unit (when available) so I can be monitored while up and about in my room or hallways ¨ Placement of internal monitors using a fetal scalp electrode and/or intrauterine pressure catheter if medically necessary ¨ Whatever is recommended by my physician for the safety of myself and baby Intravenous Access (IV) • I prefer to have IV access using this method: ¨ Saline Lock – access into a vein with short tubing and no fluid attached ¨ Continuous IV – access into a vein with tubing and fluids attached Pain Management • I plan to: ¨ Labor and give birth with little or no intervention so please do
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