My name is                                      and my goal is to exclusively breastfeed my baby.

The benefits of breastfeeding are very important to me and my baby. I request that these strategies to help me successfully breastfeed be supported as long as it is medically safe for my baby.

My Breastfeeding Plan – check all that apply

Exclusive Breastfeeding
My goal is to exclusively breastfeed my baby. Please do not give my baby any supplements such as formula, water, and glucose water, before speaking to me or my partner or support person. I need all of my baby’s suckling to be at my breast in order for me to establish a good milk supply.

No bottles or pacifiers
Please do not give my baby bottles or artificial nipples, including pacifiers. If I need to soothe my baby I prefer to try to do so at the breast or through skin-to-skin cuddling. If there is a medical reason for supplementation I would like to try alternate feeding methods with my expressed colostrum milk.

When my baby is born, I would like to have him or her placed on my chest immediately after birth, skin-to-skin for the first hour or until after the first feeding or for as long as I wish. A warm blanket may be placed over us for warmth, but not between us. If possible, please perform routine newborn evaluations with my baby on my chest.

First Hour
I would like to initiate breastfeeding within one hour following birth, when my baby shows he or she is ready to feed. This means placing my baby skin-to-skin as soon as possible after birth and offering help, if needed, to begin breastfeeding when he or she seems ready such as rooting, or licking their lips. Please do not force my baby to take the breast if he or she is not showing signs of readiness. Instead, keep my baby skin-to-skin with me until he or she is ready to try to latch.

Breastfeeding Assistance
Please teach me how to identify a good latch and how to tell if my baby is breastfeeding well; and explain to me how to correct my baby’s positioning and latch if improvement is needed.

Routine Exams
Please examine my baby in my presence and do not take him or her away from me unless he or she requires medical treatment that cannot be done in the room. If heel pricks or otherwise potentially uncomfortable procedures are done, please inform me so I can hold my baby skin to skin or breastfeed immediately before, during or after to comfort my baby.

Rooming In
I would like to have my baby room-in 24 hours a day so that I can learn his or her feeding cues and feed him or her whenever and for as long as they need to. Please encourage me to feed based on my baby’s hunger cues, and not based on the clock or a schedule. If for some reason my baby is not in my room, please bring him or her to me at the earliest hunger cues, such as sucking on hands, making sucking noise, rapid eye movement, or rooting.

Caesarean Section
If I have a Caesarean section, I would like to hold my baby skin-to-skin as soon as possible after the operation. If I am unable to for some time after the delivery, then please  allow my partner or support person to hold my baby skin-to-skin.

Hand Expression
Please assist me to hand express my colostrum milk. If my baby and I are separated due to medical reasons, help me to hand express within one hour after birth and at least eight times in 24 hours to establish and maintain my milk supply and get the milk to my baby.

Special Care Nursery
If my baby needs to go to the Special Care Nursery, please give me every possible opportunity to feed him or her and provide skin-to-skin care. If breastfeeding is not possible because of my baby’s medical condition, I would like to try an alternate method such as cup feeding.

Breastfeeding Support After Discharge
I would like a copy of Your Guide to a Healthy Newborn where community breastfeeding clinics and supports are listed in the back of the booklet.

For more information, call Health Line at 519-271-7600  or 1-877-271-7348 extension 267.

The original version of this content was developed by the Department of State Health Services, an agency of the State of Texas. They provided this content ‘as is’ without warranty of any kind. This content has been altered from its original version and represents a derivative work.

May 2019