Wednesday, February 27, 2013

Our Hospital Birth Plan and Notarized Affidavit

There have been many issues lately where parents find themselves dealing with hostility and abuse of power when simply exercising their rights to refusal of unnecessary routine newborn procedures. After dealing with a nightmarish ordeal with one of my older children, I arrived at the hospital fully prepared with this birthplan when I went into labor with my 3rd child in order to outline my objections to certain treatments and the laws that protect my rights of refusal. I would like to share this birth plan with my readers, so that you may edit it to fit your own needs, and "arm" yourself against the threats and pressure that too many parents face from medical staff. Even if you are planning a home birth, it is important to know your rights and have a birth plan on hand in the event of a hospital transfer.

I would like to note that I did not 100% write this plan on my own. I took bits and pieces of other birth plans that I stumbled upon online and edited them to fit my personal preferences. This was about 3 years ago, so I unfortunately do not have the exact sources that I borrowed some of the wording from for crediting purposes. Please just be aware that this useful and effective birthplan is the result of the work and knowledge of many dedicated parents. I wish to share this only for the purpose of allowing other parents to have an easier time protecting their rights during a hospital birth. I have also edited our names out of them to protect our privacy.

The first portion of this Birth Plan briefly outlines our wishes and preferences before, during, and after birth.
The second portion is an Affidavit which points out health-related, conscientious, and spiritual objections to certain procedures; as well as the laws, Constitutional ammendments, and the Supreme Court case which protects our refusal. This is the portion that my husband and I got notarized prior to the birth. (It is not meant to be italicized, but for some reason, it wouldn't let me change it when I pasted it on here).

Note: It is ILLEGAL for any hospital staff member to ask you what religion you are, or to attempt to dispute your spiritual beliefs. Know your rights!

BIRTH PLAN FOR {Mother's Name}, {Hospital}
We are looking forward to the birth of our third child, a son, at {Hospital name} this fall. We understand that certain emergency or other medical circumstances may not allow for the accommodation of the goals listed below. The mother's previous labors have been short and uneventful, so we are not anticipating any problems. We ask that the following wishes be respected during this birth.
Home Labor Goals
  • We would like to labor at home as long as possible, before going to the hospital.

Hospital Labor Goals
  1. We plan to have present at this birth our Midwife, and the Father, {father's name} for support. We ask that ALL other visitors and unnecessary staff be turned away until we (the parents) have had time alone with our new son.
  2. The birth environment is very important to us. For that reason we ask that the lights be kept dim, noise be avoided and the door closed for privacy. We will bring our own music.
  3. The mother would like to wear her own clothes during the birth.
  4. We are attempting to have a natural birth, which we believe to be birth without medical and/or chemical intervention. We do understand that there are procedures which may be necessary. Except in the case of an extreme emergency, we ask that we be given the opportunity to accept or refuse any procedure.
  5. The mother prefers not to have an IV administered unless determined to be required for another procedure to facilitate delivery.
  6. The mother prefers not to have a catheter unless determined to be required for another procedure to facilitate delivery.
  7. If induction becomes necessary, we ask that non-chemical induction methods (walking, breast stimulation, castor oil, sexual intercourse) be tried before chemical methods. If chemical methods do become necessary, we prefer to use the cervical cream before trying pitocin.

    Birth and Delivery Goals
  8. We plan to handle pain with relaxation, massage, and water. Please do not offer chemical pain relief.
  9. We plan to use the squatting or semi-squatting position for pushing. If labor or delivery seems stalled, we would like the opportunity to try different positions (hands and knees, squatting, birth stools, etc.).
  10. The mother would like to push at her own pace. (Mother-Directed Pushing) And if time permits, The mother would like to feel our son's head as he descends.
  11. The mother prefers not to have an episiotomy unless determined to be medically necessary. She would first like to try perineal massage, support and warm compresses.
  12. The father would like to be included fully in the "catching" of our son and cutting of the cord.
  13. We would like to have the baby placed on the mother's chest with skin-to-skin contact immediately after the birth and for the first 1 to 2 hours following the birth.
  14. After the birth, we wish to nurse our son immediately. We ask that any evaluations be done while The mother is holding him.
  15. We ask that the cord not be cut until it stops pulsing.
  16. If Cesarean becomes necessary, The mother would like to be conscious, The father would like to be present at all times and we still prefer for our son to be nursed immediately.
Newborn Care Goals
  1. Please do not administer the eye medication and vitamin K shot.
  2. We would like to be the one's to give the baby's first bath.
  3. We would like to have a set of footprints stamped into our scrapbook when footprints are done.
  4. We do NOT wish to circumsize our son.
  5. We would like to establish breastfeeding. Please do not offer any bottles to the baby without parents' notification of an emergency medical need.
We thank you for taking the time to help us achieve a natural birth for our son!



We, _________________________, Sui Juris, Free, Natural Flesh and Blood Human Beings, state Citizens of the Texas Republic affirm: Be it known to all courts, governments, and other parties that:

Being people of Strong Religious/Conscious Morals, it is against our Deep, Sincerely Held, Religious Convictions to accept the injection of any foreign substance into our Bodies or the Body of our Child. This includes, but is not limited to, any and all, Vaccinations, Shots, Tests for Diseases, Oral Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses, Pathogens, Germs, or any other Microorganisms, may be introduced into or upon our newborn's body.

This written statement to exempt our newborn from any immunizations, newborn screening, and the Vitamin K shot, because we hold genuine and sincere personal religious beliefs which are inconsistent with these medical procedures & experimentation. The practice of vaccination and the injection or application of any foreign substance is contrary to our conscientiously held religious beliefs and practices, and violates the free exercise of our religious principles.

The Hepatitis-B vaccine supposedly protects against a disease that is only transmitted through multiple sexual partners or street IV drug users and therefore usurps our parental authority to condemn such activity in our child. The acceptance of this vaccine promotes sexual promiscuity and immoral behavior in direct contradiction to the teachings of our faith.

The prescribing information on Vitamin K shot states that fatalities are an adverse reaction according to the Merck pharmaceutical package insert.

"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)." A conflict arises because our religious convictions are predicated on the belief that all life is sacred. God's commandment "Thou Shall Not Kill" applies to the practice of injection of carcinogenic substances that can kill.

We _________________ and ___________________, as the parents of ______________________(name of newborn child) are exercising our rights under the First Amendment of the US Constitution, Tex. Health & Safety Code Ann. § 33.012, and Texas Administrative Code §37.54, to receive Religious Exemption from Vaccination, ALL injections, & testing.

Applicable law has been interpreted to mean that a religious belief is subject to protection even though no religious group espouses such beliefs or the fact that the religious group to which the individual professes to belong may not advocate or require such belief. Title VII of the Civil Rights Act of 1964 as amended Nov. 1, 1980; Part 1605.1-Guidelines on Discrimination Because of Religion.

Our legal rights are guaranteed by the free exercise clause of the First Amendment to the U.S. Constitution. Recent court decisions have upheld the rights of individuals seeking exemptions from immunizations based upon personal and religious reasons. On the U.S. Supreme Court level in Frazee V. Illinois Dept. of Security, 489 U.S. 829, it was found that a state may not deny an exemption simply because a person is not a member of a formal religious organization.

The Lord and Our Creator are the only source of protection of our bodies and that of our family that we can accept.

We affirm that vaccination & injections of any foreign substances and proteins conflict with our religious beliefs as stated above. Therefore, we would request that you accommodate our religious beliefs and practices by exempting our newborn child from any vaccinations, injections and testing of any kind.

Rest assured that my family and I do practice a form of immunization that keeps our immune systems strong and is in keeping with Religious principles.

Further Affiant Saith Not

The use of notary below is for identification only, and such use does NOT grant any jurisdiction to anyone.

Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name Below)

Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

Signature of Affiant


state of Texas

county of _________________:

On this _______ day of ______________, 200__, before me

personally appeared __________________________________, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he executed the same as his free act and deed, for the purposes therein set forth.

(Notary Public)

My Commission Expires ______________________________, 200___



I sincerely hope that, after editing these statements to fit your personal needs, that you will find them helpful during your labor, birth, and postpartum hospital stay and thereafter.

Boheme Mom

1 comment:

  1. Thank you for posting this! Many of my preferences are on your birth plan. I'm excited to know these things can be listed, and hopefully, respected in the hospital.