Appendix A Perinatal palliative care birth plan checklist
| Perinatal palliative care birth plan checklist | |
|---|---|
| Family members | Mother, father/partner, other family members Name of baby (if named already) Name and number for support persons e.g. family, pastoral care, friends who the parents want involved |
| Team members | Name and contact numbers for treating team |
| Summary of the pregnancy and details of the diagnosis | Diagnosis and expected prognosis Expected date of delivery Any prenatal discussions, education and support |
| Parents’ wishes and goals for their baby | Labour and delivery If baby survives delivery |
| Care of mother antenatally | Antepartum care and extent of investigations such as ultrasounds, amniocenteses, etc. |
| Care during labour and delivery | Timing, mode and place of delivery Fetal monitoring – use during labour with possible interventions if the baby should show signs of distress Pain management and physical care of mother |
| Care of the baby at birth | Extent of resuscitative measures to be provided Pain and symptom management Comfort measures for the baby – skin-to-skin contact, bonding, feeding, temperature control, etc. Spiritual care to be provided such as rituals, religious traditions and by whom Other family members to be present Naming baby (if not named) Memory-making activities |
| Care if baby survives beyond delivery | Stay with parents or be transferred to NICU/nursery Newborn care such as bathing, dressing and feeding Pain and symptom management Extent of routine procedures such as heel pricks, blood sampling, suctioning, etc. Discharge planning – local hospital, home, hospice, etc. |
| End-of-life care | Information given to the parents about the dying process Pain and symptom management Comfort care measures Place of death – privacy to be provided in postnatal ward, nursery or NICU Family members to be present including siblings and grandparents Memory-making activities Spiritual care to be provided such as rituals, religious traditions and by whom Notification and certification of death Genetic testing, tissue sampling, autopsy Funeral arrangements |
| Bereavement support | Arrange follow-up appointments Referral to support groups or grief counsellors if available Give out brochures or pamphlets if available |
