Birth Plans - Checklist (Page 6 of 8) in pdf

Birth Plans - Checklist Page 6

Name : _____________________________________

Spouse/Partner : _____________________________

M.R. No : ______________ Date : _______________

Desired Hospital :

Unit I – Bogulkunta

Unit II – Hyderguda

Name of Consultant: __________________________

EARLY/FIRST STAGE LABOUR

Environment :

Wear own clothing

Coach/partner only desired attendees other

than medical staff (maximum 2 people)

I would prefer to wear my contact lenses/

glasses

Mobility (choose one) :

Unlimited freedom to move (walking, bathroom,

rocking chair, fitness ball, etc.)

Mobility is not important to me

I.V. :

I.V. insertion is acceptable at any point

I.V. placement should be attempted only if dehy-

dration occurs

Please attempt to insert I.V. on left/right (circle)

Monitoring (choose one) :

Intermittent monitoring (Fetoscope, Doppler, etc.)

No monitoring except in emergency situations

Catheterization :

I would like to avoid catheterization unless it is

absolutely necessary

Pain Relief Offer (choose one) :

Do not offer; I will ask if I desire it

Offer if I appear uncomfortable

Offer as soon as possible

Pain Relief Options :

Natural

Relaxation techniques

Hot or cold compresses

Birth Plans - Checklist Page 6