バースプランのサンプル

 

*英語のバースプランのサンプルです。下記の部分を印刷してお使いください。

希望する項目にチェックをつけ、担当医にご相談ください。そして、担当医にサインをもらい、3枚コピーして1枚は自分用に保管し、担当医と出産のときに立ち会う看護婦(当日でも可)に渡しておきましょう。

 


 

BIRTH PLAN

by  

Name: (                        )
     
Date:  (               )
1) Admission Procedures    

(    )

NO Enema

(    )

NO Shave
2) Labour
(    ) Partner / birth companion to be with mother at all times
(    ) Fetal monitoring --- test for half-hour only on admission
(    ) NO continuous electronic fetal monitoring throughout labour
(    ) NO intermittent fetal monitoring --- doppler or fetal stethoscope
(    ) Freedom to move around and choose positions of maximum comfort
(    ) Food and fluids as desired during labour
(    ) Information on risk and benefits of any medical procedures suggested during labour
(    ) NO artificial rupture of the membranes
(    ) NO use of artificial hormones to 1) induce labour 2) increase contractions 
(    ) Pain medication at the request of the mother
3) Birth

(    )

Mother to choose position for birth

(    )

To commence pusing according to mother's spontaneous urge

(    )

NO directed pushing
(    ) NO time limit on second stage if condition of mother and baby is satisfactory and progress is being made
(    ) NO episiotopy
(    ) Air-conditioning to be switched off at time of delivery
(    ) Baby to be given straight to mother
(    ) NO early / late cord clamping
(    ) NO use of hormone injection after delivery to speed up exposition of placenta
(    ) Father to cut the cord
(    ) Baby to breast in delivery ward
(    ) Father to be present for caesarian delivery
4) Post-natal
(    ) Rooming in at all times
(    ) Breastfeeding on demand
(    ) Assistance with breastfeeding if required
(    ) Supplements to be given by cup, spoon or syringe if medically required (NO bottle and teas to be used)
      (    )      Assistance with milk expression within a few hours of birth if mother and baby are separated
  If any medical complications arise during late pregnancy or labour, then this birth plans may
have to be revised or abandoned.

  These birth plans are approved by 

 signature:                    Dr.'s name: (                           )  Date: (                    )         

 


 

 

 

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