Birthing plans, by their nature, may be subject to changes in your health, the policies of your delivery hospital, and your needs as you progress in labor. We encourage you to understand your alternatives, discuss the issues



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Women’s Health Practice Birth Plan

Birthing plans, by their nature, may be subject to changes in your health, the policies of your delivery hospital, and your needs as you progress in labor. We encourage you to understand your alternatives, discuss the issues, and be prepared to be somewhat flexible. The birth of a child can have many roads and paths to get to that finish line and we want your experience to be a great chapter in your life.

Check all that apply.

My name is _________________________________________________________

My Partner/Support Person _________________________________________________________

___ I will be using a Doula Service for my delivery:

Doula’s name _________________________________________________________

I am planning to deliver at:

___ Carle: ___ 4th Floor ___ 10th Floor

___ Presence Covenant

___ My chosen Pediatrician’s name is: _____________________________________

___ I am planning to store my baby’s cord blood and have kit.

___ I would like to take home the placenta after delivery. ***TO REQUEST THIS YOU MUST TELL NURSING STAFF AT TIME OF YOUR ADMISSION TO HOSPITAL*** PLEASE BE AWARE THAT DUE TO HOSPITAL POLICIES OR IF THERE ARE ANY INDICATION OF INFECTION OR OTHER MEDICAL ISSUES THAT REQUIRES TESTING OF PLACENTA THIS REQUEST CAN NOT BE GUARUNTEED***



PREGNANCY HISTORY

___ I have been diagnosed with a high risk pregnancy ___ My Blood Type is RH

___ I have tested positive for Group B Strep ___ I have gestational diabetes

___ I have had a history of Herpes Virus ___My vision is impaired

___ I am hard of hearing ___ I have had a previous Cesarean section

FOR THOSE WHO HAVE HAD A PREVIOUS CESAREAN SECTION

___ I have read and signed the VBAC consent requesting a repeat C/S

___ I have read and signed the Women’s Health Practice VBAC consent declining a repeat C/S with plans to attempt to VBAC

___ I am scheduled for a repeat C/S on _________________



PREPARATION CLASSES

I have attended or plan to attend the following classes

___ Childbirth / Lamaze ___Lactation

___ Bradley ___Sibling Classes

___ Other: _____________________________________________________

ENVIROMENT

___ Dim lights ___ Music

___ Quiet ___ NO interns, students, or unnecessary staff in room without my permission

___ I would like doctors and staff to discuss all procedures with me before they are preformed



MOBILITY ***DUE TO SOME MEDICATIONS OR OTHER MEDICAL RISK FACTORS MAY VOID FREEDOM OF MOVEMENT***

___ Walking, rocking, up to bathroom, etc. ___ Mobility not important



HYDRATION ***AS ALLOWED BY SITUATION***IV ACCESS IS REQUIRED AT ALL TIMES DURING LABOR AND DELIVERY***

___ I prefer to eat and drink throughout labor ___ Ice chips



MONITORING ***DUE TO HOSPITAL POLICIES AND STANDARDS OF CARE YOU MAY BE REQUIRED TO HAVE CONTINUOUS MONITORING AT ALL TIMES***

___ Intermittent monitoring ___ Telemetry monitoring (if available)



LABOR / INDUCTION / AUGMENTATION ***IV ACCESS WILL BE REQUIRED***

___ I am scheduled for induction on ________________________________ I have signed induction / Pitocin orders

___ I would like my support person with me at all times ***Due to hospital policies the support person is not allowed to accompany patient during procedures done under general anesthesia, this includes C/Ss that require general anesthesia***

___ I would like to labor in shower ___ No shaving or enemas

___ I would like to labor in tub ***Once membranes have ruptured you may not be able to labor in tub depending on hospital policies and medical history***

___ I would like to avoid any induction of labor

___As long as baby and I are healthy, I do not want to discuss induction of labor prior to 42 weeks

___ I would like to try natural methods to induce labor, walking, nipple stimulation, etc.

___ I do not wish to have my membranes ruptured artificially

___If labor is not progressing. I would like to have artificial rupture of membranes before other methods are uses to augment labor



CESAREAN

___ I am planning to have an elective C/S

___ If a C/S delivery is indicated, I would like to be fully informed and participate in decision-making process

___ I would like my partner / support person ___________________ present at all times if a C/S is required ***Partners / support person is not allowed in surgery when C/Ss are done under general anesthesia***

___ I would prefer spinal anesthesia

___ I would like to have an epidural bolus, if epidural has already been placed

___ I would like the screen lowered just before delivery of baby

___ If baby is not in distress, I would like baby to be given to ________________



PAIN RELIEF

___ Only if I ask ___ Offer pain medications as soon as possible



VAGINAL DELIVERY

___ I would like to wait for the urge to push ___ I do not want to use stirrups to push

___ I would like to choose positions to use for pushing

___ I would like a mirror to see baby’s head

___ I would like to touch baby’s head as it crowns

EPISIOTOMY / FORCEPS / VACUUM

___ I would like to avoid any type of artificial delivery unless for the safety of baby

___ I would like perianal massage to avoid need for episiotomy

___ I would rather tear than have an episiotomy

___ I would rather not use forceps in my delivery unless there is medical need

___ I would rather not use a vacuum in my delivery unless there is medical need



AFTER DELIVERY

___ I would like ______________________________ to cut the umbilical cord

___ I would like to cut the umbilical cord myself

___ I would prefer the umbilical cord stop pulsating before it is cut

___ I prefer to wait for spontaneous delivery of placenta

___ I would like baby to evaluated and bathed in my presence

___ If baby must be taken from room I would like ________________________ to go with baby if possible ***If baby needs to be admitted to NICU or a higher level of care parents are not allowed in for initial admission process. Parents will be taken to NICU once admission has been completed on baby***

POSTPARTUM

___ I would like my other children to be able to visit ***DURING FLU SEASON THERE CAN BE RESTRICTIONS ON THE ADMITTANCE OF ANYONE UNDER THE AGE OF 18 TO MATERNAL/CHILD UNITS, FOR THE SAFETY AND WELL BEING OF OTHER MOMS AND BABIES ***

___ I am RH– and will need Rhogam

___ I would like my partner / support person to room in with me

___ I would like to be released after 24 hrs from delivery time if possible

___ I understand postpartum depression signs



NEWBORN CARE

___ I would like my baby boy circumcised ___ I do not want my baby boy circumcised

___ Breastfeeding only ___ No pacifiers or glucose water

___ Formula feeding only ***I WOULD LIKE HOSPITAL STAFF AND OFFICE STAFF TO UNDERSTAND THAT I CHOOSE NOT TO BREASTFEED, AND NOT TRY TO CHANGE MY MIND***



___ Breastfeeding and formula feeding

___ I would like to see the lactation consultant during my stay in the hospital


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