Preview Mercy Birth Plan

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 ﬂowers-

please 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 don’t oer pain medication. I will let

you know if I change my mind.

¨Narcotic pain medication given into my IV if

safe for me and my baby

¨Epidural anesthesia

Bag of Water Breaking • I would prefer to:

¨Allow my bag of water to break on its own

¨Have my bag of water artiﬁcially broken if

medically necessary

Pushing Preferences and Birth • I would like to

try (check all that are desired):

¨Lying on my side to push

¨Squatting in bed using the squat bar

¨Sitting upright in bed

¨On all fours

Episiotomy • I would prefer to:

¨Not have an episiotomy

¨Whatever is recommended by my physician

for the safety of myself and baby

Cutting the Umbilical Cord • I plan to:

¨Have my labor partner cut the umbilical cord

¨I would prefer that my physician cut the

umbilical cord

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:

Partner______________________________________Relationship _____________________

Doula _____________________________________________________________________________

Other visitor___________________________________Relationship_____________________

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