Modèle de Plan de Naissance
Modèle de Plan de Naissance: Préférences d'Accouchement, Soulagement de la Douleur et Soins du Nouveau-Né
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Parent Information
Labor Preferences
I would like to:
Preferred positions for labor:
Pain Management
Monitoring Preferences
Interventions
I would like to avoid:
Support During Labor
Delivery Preferences
I would like to:
After Birth
I would like:
Baby Care
Unexpected Situations
If a C-section is required, I would prefer:
Additional Notes
Signature
Aperçu
Birth Plan
This Birth Plan ("Plan") is prepared by:
Parent's Name: [Your Full Name]
Expected Due Date: [Date]
Hospital or Birthing Center: [Facility Name]
Care Provider: [Doctor / Midwife Name]
Support Person(s): [Partner, Doula, Family Member]
This Plan outlines my preferences for labor, delivery, and immediate postpartum care. I understand that flexibility may be required based on medical circumstances.
1. Labor Preferences
I would like to:
2. Pain Management
I prefer Unmedicated birth
3. Monitoring Preferences
Intermittent monitoring
4. Interventions
I would like to avoid (unless medically necessary):
5. Support During Labor
I would like the following people present: [Names of people allowed in delivery room]
6. Delivery Preferences
I would like to:
7. After Birth
I would like:
8. Baby Care
- Breastfeeding only
- Vitamin K: Injection
- Eye ointment: Accept
- Hepatitis B vaccine: Accept
9. Unexpected Situations
If a C-section is required, I would prefer:
Acknowledgment
I understand that while every effort will be made to follow this Plan, medical needs and circumstances may require adjustments. I trust my care team to act in the best interest of myself and my baby.
Signature
Name: ___________________________
Date: [Date]
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