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.
Please check all that apply then click the CREATE BIRTH PLAN button at the bottom of this page. Please print the page since it will not be saved.
My name is
I am planning to deliver at: Provena Covenant Carle Foundation
I have had an ultrasound. I have had Baby Love Keepsake photography. I have had a perinatal consult. Medications I take:
My support person will be: NOTE: Standard of care allows only 3 support people present during your labor and delivery.
1. Preparation
I have taken a prepared childbirth class for a previous pregnancy. I have taken a prepared childbirth class. I have signed up with a Dula: Name Phone
2. Environment
Check as many as you would prefer: Dim lights Peace and quiet Music 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.
3. Mobility
You may only select one: Maintain mobility (walking, rocking, up to bathroom, etc.) Mobility not important (catheter, used with epidural)
4. Hydration
You may choose a selection of these: I prefer to eat and drink throughout labor, as desired. Ice chips, standard with epidural. So I can stay as mobile as possible, I would prefer to have a heparin/saline lock (most hospitals require this as access to a vein should an emergency occur; it can also be used in place of an IV for administration of antibitiocs for complications, such as MVP or Beta Strep).
5. Monitoring
Labor admission policies usually require a short period of electronic monitoring to document that the fetal heart rate is normal on admission.
As long as the baby is doing well, I prefer that fetal heart tones be monitored intermittently with an external monitor or Doppler, unless it is required by the condition of the baby. Note: You should know that continuous monitoring is the standard of care at Provena Covenant and Carle Foundation Hospital.
OTHER OPTIONS I'm interested in ambulatory monitoring if the telemetry unit is available. (Not currently available at Provena Covenant)
6. Labor Augmentation/Induction
I would like to avoid induction unless it is medically necessary. I am scheduled for an induction for on . 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 before pitocin or artifical rupture of membranes: Natural methods (walking, nipple stimulation, sex, etc.)
7. Pain Relief Medication/Anesthesia
Please do not offer anesthesia/analgesia unless I ask for it. I prefer natural pain relief methods (relaxation, positioning, water-shower or tub access, heat or cold therapy, massage, acupressure). Before considering an epidural and if the situation warrants, I would like to try an injection of narcotic pain relief. I would like to have an epidural.
OTHER I would like the epidural to wear off slightly as I approach full dilation and the pushing stage. Note: I understand that it is the job of the anesthesiologist to manage the epidural dosing and I anticipate discussing my case with them.
8. Delivery
I would like the freedom to push and deliver in any position I like. I would like to have a mirror available and adjusted so I can see the baby's head crowning. I would like the opportunity to touch my baby's head as it crowns. I would like to have the birth recorded with photographs, videotape, and/or tape recording. The hospital policy of Carle and Provena is not to permit videotaping during the delivery.
OPERATIVE DELIVERY I would allow vacuum delivery. There are several vacuum devices available, some newly designed for safety. Vacuum sometimes are needed to assist fetal head delivery at Cesarean section.
9. Episiotomy
NOTE: Our standard of care is that an episiotomy is avoided unless required for the baby’s safety.
I understand what an episiotomy is. I need more information. I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage. I would appreciate guidance in when to push and when to stop pushing so the perineum can stretch.
10. Immediately After Delivery
I would like to have cut the cord. I would like to hold the baby while I deliver the placenta and any tissue repairs are made. Please show me the placenta after it is delivered.
I understand cord blood storage, and I have received information on this. I have not received information on this.
I am planning to store my baby's cord blood and I have the collection container from:
11. Cesarean
I feel very strongly that I would like to avoid a Cesarean delivery. If a Cesarean delivery is indicated, I would like to be fully informed and to participate in the decision-making process. I would like present at all time if the baby requires a Cesarean delivery. Spinal anesthesia is generally used for the procedure. General anesthesia would be needed in an emergency only or if you have history of certain back conditions. So I can view the birth, I would like the screen lowered just before delivery of the baby.
12. For Those Who Have Had A Previous Cesarean Section
Most of the rest of these sections will not apply to your case. I have read and signed the Women's Health Practice VBAC consent requesting a repeat Cesarean section. I have read the Women's Health Practice VBAC consent, and I am declining a repeat Cesarean section and plan to attempt a VBAC. I have been scheduled for a repeat Cesarean section on .
13. Tubal Ligation/Essure
This is designed for permanent sterilization. You may not be able to have a tubal ligation if you are planning to deliver at a Catholic institution. Please discuss with your physician. I wish to have postpartum tubal ligation/or Essure procedure. I wish to have a tubal ligation with my Cesarean section. I have signed the necessary sterilization papers.
14. Afterbirth Care
I would like to hold the baby before (he/she) is photographed, examined, etc. I would like to have the baby evaluated and bathed in my presence. If the baby must be taken from me to receive medical treatment, or some other person I designated will accompany the baby at all times.
15. Newborn Care
My chosen Pediatrician's name is:
(A) CIRCUMCISION Please choose only one category or leave blank if your baby is a girl. None In the hospital In the pediatrician’s office
(B) FEEDING BABY Choose one feeding method, and you have an additional option for pacifiers. Breast feeding only Bottle feeding only Combination No pacifiers or glucose water. I would like more information about breastfeeding. I would like to meet with a lactation consultant.
(C) SEPARATION Choose only one, although you can change your mind after the birth. Unless required for health reasons, I do not wish to be separated from my baby. I would like to have the baby "room in" and be with me at all times. I would like the baby with me during the day but in the nursery at night. I would prefer the baby be kept in the nursery and brought to me upon request.
(D) NEWBORN SCREENING (in accordance with Illinois State Law) I agree to standard newborn screening tests, these should include Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency (incidence in newborns 1 in 15,000), Phenylketonuria (PKU) (incidence in newborns 1 in 12,000), Congenital hypothyroidism (incidence in newborns 1 in 4,000), Congenital adrenal hyperplasia (CAH) (incidence in newborns 1 in 5,000), Biotinidase deficiency (incidence in newborns 1 in 70,000), Maple syrup urine disease (incidence in newborns 1 in 250,000), Galactosemia (incidence in newborns 1 in 50,000), Homocystinuria (incidence in newborns 1 in 275,000), Sickle cell anemia (incidence in newborns among African Americans 1 in 400; incidence in newborns among Hispanics 1 in 1,000 to 30,000 depending on the region); less common in others).
16. Postpartum
I am Rh negative blood type and will need Rhogam. My Rubella titer is low and I will need Rubella vaccination before leaving the hospital. I would like my to room-in with me. Assuming I feel up to it and the baby is healthy, I would like to be released from the hospital as soon as possible following the birth. I understand postpartum depression signs. I have been told that: I am at risk. I am not at risk.