Surrogacy Birth Plan - Surrogacy in Canada Online

We encourage you to create a birth plan, as the birth plan is an ideal way to communicate your preferences.

Feel free to fill this page out then you can email the document to yourself to print or keep for your records.

Email Address:(Required)

Your email to send the filled in document to.

Surrogate Mother:

Intended Parent(s):

Surrogate Support:

Doctor/Midwife:

Doula:

Birth Photographer:

I’D LIKE THE FOLLOWING PRESENT DURING LABOUR/DELIVERY:

Partner:

Parents:

Intended Parent(s):

Other Children:

Doula:

Other:

PLEASE NOTE:

I have tested positive for Group B Strep.

My bloodtype is Rh- (Rhesus Negative).

I have gestational diabetes.

I am diabetic.

I am hard of hearing.

My vision is impaired.

I would like to wear contact lenses or glasses at all times when conscious.

Additional:

MY DELIVERY IS PLANNED AS:

Vaginal

C-section

Water birth

VBAC (Vaginal Birth After Caesarean)

Home birth

LABOUR:

Additional :

LABOUR INDUCTION/AUGMENTATION:

I would like to avoid induction unless it is medically necessary (baby is in distress or my health at risk).

As long as the baby and I are healthy, I do not want to discuss induction prior to 40 weeks.

If my pregnancy progresses past 40 weeks, I would prefer to base the decision to induce on the results of the baby's biophysical profiles, not on my own personal discomfort or impatience.

I would like to try alternative means of labor augmentation, like walking or nipple stimulation, before pitocin or artificial rupture of membranes is attempted.

If induction is necessary, I would like to attempt it with prostaglandin gel or another means before pitocin is administered.

If induction is attempted, but fails, I would like to come back at another time rather than pursue further intervention (assuming my membranes are intact and that waiting presents no danger to the baby or myself).

Please do not rupture my membranes artificially unless medically indicated.

Additional :

ANAESTHESIA/PAIN MEDICATION:

Please do not offer anesthesia/analgesia unless I ask for it.

If I ask for pain relief, please feel free to offer non-medical choices for coping and/or remind me how close I am to the birth.

I would like to avoid all narcotics, if possible.

I prefer an epidural to narcotic pain medication.

If pain relief is considered, I would like to try a narcotic before an epidural.

I would like to have an epidural as soon as possible.

I would like to have a light dose (walking) epidural.

I would like the epidural to wear off slightly as I approach full dilation and the pushing stage.

Additional :

CAESAREAN SECTION DELIVERY:

People to be present during the surgery:

Additional :

PERINEAL CARE:

I prefer not to have an episiotomy unless it is medically indicated (last resort).

To avoid episiotomy or tearing, the following person (listed below) or my labor assistant will perform perineal massage with oil and apply hot compresses.

To help my perineum stretch, please help guide my pushing efforts by letting me know when to push and when to stop.

I would rather tear than have an episiotomy.

I would rather have an episiotomy than risk a tear.

Please administer local anesthesia when repairing any episiotomy or tear(s).

Please suture tears only if necessary.

Person to perform perineal massage:

Additional :

DELIVERY:

Person to help supporting my legs as I push:

Additional :

AFTER BIRTH:

Additional :

NEWBORN CARE:

We would like the baby to have skin-to-skin contact with the Intended Parent(s) during the first hours to help regulate baby's body temperature.

Please evaluate and bathe the baby with the Intended Parent(s).

If the baby must go to the nursery for evaluation, medical treatment or hearing tests, please allow the Intended Parent(s) to accompany the baby at all times.

Please delay eye medication for the baby until we are well past the initial bonding period (a couple hours after the birth).

The Intended Parent(s) would like to defer the following vaccinations/medications for the baby:

POST PARTUM:

If available, I would prefer a private room.

If available, I would like to have a postpartum room away from the rooms of other women who have recently given birth.

I would like to have the Intended Parent(s) and baby room-in with me at all times.

If available, I would like to have the Intended Parent(s) and baby have a private room.

If the Intended Parent(s) have not arrived, I would like the baby to room-in with me.

If the Intended Parent(s) have not arrived, I would like the baby to room-in with me during the day, but stay in the nursery at night.

If the Intended Parent(s) have not arrived, I would like the baby to remain in the nursery.

Assuming I feel up to it I would like to be released from the hospital as soon as possible following the birth.

Additional :

BREASTFEEDING:

I am planning to express breast milk for the Intended Parent(s) to feed the baby.

The Intended Parent(s) plan to breastfeed immediately following the birth.

Please do not give the baby supplements (including formula, glucose) without consent from the Intended Parent(s), unless there is an urgent medical necessity.

Please do not give the baby a pacifier.

I will require assistance with pumping breastmilk and would like to meet the staff lactation consultant.

The Intended Parent(s) would like to meet with the staff lactation consultant.

The baby will be formula fed only.

Additional :

ADDITIONAL NOTES:

We would like to take photographs during labour, birth and post partum.

We would like to make a video recording of labor, birth and post partum.

We would like to have photos only together after the birth.

We would like to have no photos or videos at any time.

The Intended Parent(s) is/are planning to have the baby circumcised.

The Intended Parent(s) is/are NOT planning to have the baby circumcised.

Please address me directly with any questions relating to the birth and my options. Once the baby is born, any medical questions regarding the baby should be directed to the baby’s parent(s).

We would like our surrogate and her partner/child(ren) to have time to meet and hold the baby.

Additional :