Dear expecting mothers and fathers
Here are three documents to be signed andpresented to a midwife upon your check-in forthe child birth.

Please have the documents

ready in your bag-for-the-day.
If there is any questions, please let me know.

Important notice:

Our anesthesiologist requests removal of all

makeups including manicures and pedicures. Failure to do so may
result in cancellation of the procedure.
Hideki Sakamoto MD

Birth Plan
Name（ mother ）:This is yourName（ father ）:st/ nd/ rd/ th childbirthDue date:
Consultation card No.:
―1. What kind of childbirth do you want?

2. Are you doing or trying to do anything in preparation for the childbirth?

3. What do you want people around you (your husband, family, doctor, midwife, and others) to do atchildbirth?

4. If you are a multipara, how did your last childbirth go?

It was in Aiiku Hospital／Others

5. We recommend breast-feeding. Do you have any questions regarding breast-feeding or rooming-in ?

6. What are you discussing with your husband/family regarding life after childbirth?

7. Enter whatever you want or worrying about.

8. Check the applicable item.
(1) Want to be attended by a family member.

□ Yes

□ No

(2) Want to be attended by:□ Husband□ Your mother□ Others ((3) Have you attended the mother’s class in Aiiku Hospital?

□ Yes□ No□ In other place(4) Have you attended the parents’ class in Aiiku Hospital?

□ Yes

□ No

□ In other place(5) Did you remove your ring?

□ Yes

□ No

(6) Did you remove your decoration of the fingernail?

□ Yes□ No)＊In general anesthesia, eyes are usually covered by a seal to prevent drying of eyes. Therefore you should
be sure to remove false eyelashes or eyelash extensions before hospitalization. If you do not consent tothis condition, we may not take on your childbirth or operation for safety’s sake.

Confirm on :Confirmed by : Dr. Hideki SAKAMOTO Mw※This is persistently a birth plan, not a birth contract.
We always make a effort to grant your request, however our policy, that we must have priority over the safety
for mothers and babies, is constant.
We hope you will understand that we may not follow your birth plan all the time.

2015.5

Aiiku Hospital

Information and Requests Regarding a Family Member’s Attendance at Delivery
Aiiku Hospital allows a family member in the LD (labor and delivery) Room, so that the motherto-be may undergo labor and delivery in more relaxed condition. Since the purpose of thispolicy is assisting a good delivery, we would give priority to the patient’s wishes. If urgent
medical procedures should become necessary in the course of delivery as the case may be, wemay not be able to meet your demands.

We would appreciate your understanding of thefollowing conditions and cooperation.
1 ) Only the person by whom the patient wants to be attended can enter the room.
2 ) We may request the attending person to leave the room if necessary medical
procedures demand it.
3 ) We may request the attending person to leave the room if the attendance is thought to botherthe people around.
4 ) We would basically allow the patient’s family member in. But if the patient wants to beattended by a non-family person, we will consider at request.
Basically 1 person per patient can enter the LD Room since the space is limited.
A child cannot enter the room to prevent possible infection of other patients.

Written Consent
To Director of Aiiku Hospital
Agreeing with the above statement and its meaning, I would like to attend the mother-to-be in theLD Room.
Date:
Name of the patient:
Name of the would-be attendant:

Information on Kangaroo Care
(1) What is kangaroo care?
Kangaroo care is the way in which the mother or the father folds to her/his naked bosom the naked baby who was born small
and being raised in an incubator. As it is reported to stabilize the baby's breath, heart beats, and body temperature very well,also improving therapeutic effects through direct physical contact, kangaroo care is adopted in many centers treating prematurebabies. In Aiiku Hospital, kangaroo care is available for any babies, not only for those born small. Kangaroo care is also
said to deepen the mother's joy of childbirth and love for the baby. The baby, by being folded to the mother's bosom, is calmed
down and cries less.

(2) Problem with kangaroo care
The baby, who has been provided with oxygen and nutrition from the mother through the umbilical cord for 10 months in
the womb, starts lung breathing independently as soon as it delivered into the external world. However, it is said that a few
babies, one of some 1,000 babies, cannot adapt to the rapid environmental change and may develop apnea or hypothermia afterbirth. It is undeniable that kangaroo care just after birth involves a certain risk due to lack of full observation during the care.

(3) Kangaroo care in Aiiku Hospital
Just after birth, after confirming that the baby has no major problem in condition, the baby is placed, on his/her stomach, on
the mother bosom to bosom and let stay there for about 15 minutes. The room temperature is kept constant and the baby'sback is covered with bath towel to prevent hypothermia. The staff regularly checks the baby's breath. Since observation of
the baby, who lies on his/her stomach, is very difficult, the mother or father as well as we staff is requested to watch the baby'scomplexion or other states during kangaroo care.

(4) Choice whether to do kangaroo care or not
In the current understanding, kangaroo care is a very good way to deepen the mother-child bond starting just after birth but itinvolves a risk. Of course the whole staff is prepared to exert full attention and watch to lessen the risk, all the risk cannot beavoided.
After reading the above information, each family is requested to decide whether to do kangaroo care or not.

Written Informed Consent
To Director, Aiiku HospitalWith consent to what is informed above, we request kangaroo care to be done.
Date: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Name: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿