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About SCO
SCO Team
Our Mission
Why Choose SCO?
SCO Community
SCO Surrogate Retreat
SCO FAQ
Our Media Appearances
Sally’s Surrogacy Journal
Surrogacy in Canada
Surrogacy in Canada
Egg/Embryo Donation in Canada
Canadian Fertility Clinics
Canadian Fertility Lawyers
Canadian Fertility Counsellors
Canadian Insurance Agents
Surrogacy in Canada FAQ
Surrogacy Canada Support Group
Intended Parents
Become an Intended Parent
Types of Surrogacy
Surrogacy Process
Intended Parent Qualifications
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Surrogacy Birth Plan
We encourage you to create a birth plan, as the birth plan is an ideal way to communicate your preferences.
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:
Please perform no routine prepatory tasks (shaving, enema, etc.), unless required.
I expect that doctors and hospital staff will discuss all procedures with me before they are performed.
I prefer to wear my own clothes, rather than a hospital gown.
I prefer to eat and drink throughout labor, as desired.
So I can stay as mobile as possible, I would prefer to have a heparin lock administered instead of an IV.
Please do not administer an IV or heparin lock unless there is a clear medical indication that such is necessary.
I would like a quiet, soothing environment during labor, with dim lights and minimal interruptions.
I would like to play my own music.
Please limit the number of vaginal exams.
I wish to labor freely in the birthing tub or shower.
As long as the baby is doing well, I prefer that fetal heart tones be monitored intermittently with an external monitor or doppler, even if the membranes have ruptured.
Please allow me to vocalize as desired during labor and birth without comment or criticism.
I do not mind observation by students, interns or staff.
Please do not permit observers such as interns, students or unnecessary staff into the room without my permission.
To preserve my privacy and dignity, I would prefer that everyone knock before entering.
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:
I feel very strongly that I would like to avoid a cesarean delivery.
If a cesarean is necessary, I expect to be fully informed of all procedures and actively participate in decision-making.
I would like the following people (listed below) to be present during the surgery.
Please explain the surgery to me as it happens.
I would prefer general anesthesia in an emergency only.
I would prefer epidural anesthesia, if possible, in order to remain conscious through the delivery.
I would prefer spinal anesthesia for the procedure.
I would like to have a respectful atmosphere without chatter during any part of the surgical procedure.
If conditions permit, I would like the Intended Parent(s) to be the first to hold the baby after the delivery.
If conditions permit, the baby should be given to the Intended Parent(s) immediately after the birth.
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:
Even if I am fully dilated, and assuming the baby is not in distress, I would like to wait until I feel the urge to push before beginning the pushing phase.
I prefer to push or not push according to my instincts and would prefer not to have guidance or coaching in this effort.
I do not want to use stirrups while pushing.
I would like the freedom to push and deliver in any position I like.
I would appreciate help from the following person (listed below) and staff supporting my legs as I push.
I would like to deliver in a birthing pool.
I would like to have a mirror available and adjusted so I can see the baby's head crowning.
I do not want to have a mirror available and adjusted so I can see the baby's head crowning.
I would like a soothing environment during the actual birth, with dim lights and quiet voices.
I would like the Intended Parent(s) to help catch the baby.
I would like to have the birth recorded with photographs, video tape and/or tape recording.
Person to help supporting my legs as I push:
Additional :
AFTER BIRTH:
Please place the baby on the Intended Parent(s) stomach/chest immediately after delivery.
As requested by the Intended Parent(s) I would like to breastfeed the baby immediately after delivery.
Please place the baby with the Intended Parent(s) for breastfeeding.
Please allow the Intended Parent(s) to cut the cord.
Please allow the umbilical cord to stop pulsating before it is cut.
We have made arrangements for donation of the umbilical cord blood.
We have made arrangements to bank the umbilical cord blood.
We will require assistance with umbilical cord blood collection for DNA purposes.
I prefer to wait for spontaneous delivery of the placenta and do not want a routine injection of medication to assist this.
Please show me the placenta after it is delivered.
Please remove my IV/Heparin lock/catheter as soon as possible after delivery.
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:
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 :
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