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
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