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before accepting the use of oxytocic drugs.

The baby will be placed straight on the mother's abdomen and gently massaged and caressed immediately after being born. A blanket will cover the baby and mother. The baby may be breastfed within minutes of birth and will not be wiped or cleaned in any way. If the mother is incapacitated, such care will be immediately transferred to the father.

Apgar and well baby checks will only be done by observation while the baby is on the mother unless consent is obtained by mother. Weighing and measuring are only to be done if the parents request it and much later after the birth.

The baby is not to be given vitamin K or antibiotic eye ointments. Do not carry out any procedures or treatments on my baby without first obtaining permission. This includes cutting my baby's umbilical cord, bathing or wiping the vernix off of my baby, giving my baby glucose water, antibiotics, formula, testing PKU, giving pacifiers etc.
The baby is not to be taken out of parental sight at any time. Either the mother or father must always be present.

In the event our baby is unwell:
Any procedures must be explained in full and informed, written consent must be obtained before any intervention is performed.

A parent will remain with the baby at all times - no exceptions.

The baby will only be fed breast milk. Absolutely no formula feeding or pacifier without our written consent. If none is available from me and our baby requires more than colostrum, we will discuss other options.

Even if our baby is premature, there will be no period in the nursery. Rooming in will be immediate and continuous unless there is a genuine problem with the baby and informed, written consent is obtained from the parents for treatment of the baby in the nursery.

Kangaroo care and as much skin to skin contact with parents as possible while our baby is unwell is desired.

These are our formal wishes and we desire that they be obeyed and respected to the best of the Hospital staff's ability. We recognize that some of our wishes may constitute additional personal risk to the mother and risk to our child. Our choices are firm, and we wish them to be respected under the Health Care (Consent) and Care Facility (Admission) Act. This constitutes our written consent to treatment under the circumstances listed above.

Signed,
Mother Father

Thank you for reading this and working with us to respect our wishes.

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