英 語

バースプラン
Birth Plan
～病院の方へ伝えたい出産についての希望～
Requests on childbirth to the hospital
医療関係者のみなさまへ
To hospital staff members
赤ちゃんと母体の安全が脅かされる場合をのぞき、文化、宗教、風習に出来るだけ配慮したお産をサポートして下さるとありがたいです。
It would be great if you could support my labor with as much consideration for culture, religion,and customs as possible, except in cases where the safety of my baby or me is threatened.

名前 Name
希望年月日 Date of requests【診察に関してYear:Month:Day:

Medical examination】□ 説明の時通訳を希望します
I would like to have an interpreter during the explanation.
□ 宗教上の理由から女医さんを希望します
I would like to see a female doctor for religious reasons.
□ 触診は最低限にして欲しいです
I would like palpation to be kept to a minimum.
□ 内診は最低限にして欲しいです
I would like internal examination to be kept to a minimum.
□ 毎回超音波検査をして欲しいです
I would like to have an ultrasound every time.
□ 宗教上の理由から薬はカプセルではなく、錠剤のものをお願いします
For religious reasons, prescribe medication in pill form, not capsules.
【出産の形式Ways of childbirth】□ 自然分娩を希望します
I would like to have a natural birth.
□ フリースタイルで産みたいです
I would like to have a freestyle birth.
□ 無痛分娩を希望します
I would like to have a painless birth.
□ 帝王切開を希望します
I would like to have a cesarean section.
【産前入院中Prenatal hospitalization】□入院中、お祈りする場所と時間が一日5回必要です。
(お祈り中は話しかけられても応じられません)

During hospitalization, I need a place and time to pray five times a day.
(During prayer, please don’t talk to me because i cannot respond.)□お祈りの前に毎回身体を洗う必要があるため、シャワーを使わせて欲しいです。
I need to wash my body before each prayer, so I need a permission to use the shower
5 times a day.

NPO法人Mother’s Tree Japan英 語【陣痛中During labor pains】□ 夫や家族に付き添ってもらいたいです
I want my husband or other family members to accompany me.
□ アロマを焚きたいです
I want to burn aroma.
□ 好きな音楽をかけたいです
I want to play my favorite music.
□ そばにいて欲しいです
I want you to be with me.
【出産の時 At the time of childbirth】□ 立ち会いを希望します ( 夫・実母・上の子 )I would like my (husband, mother, older child) to be present.
□ 音楽を聴きながら産みたいです
I would like to have my baby while listening to music.
□ 会陰切開しないで欲しいです
I do not want to have an episiotomy.
□ 臍帯をすぐに切らないで欲しいです (赤ちゃんへの臍帯血の移行が終わるまで)
I do not want the umbilical cord to be cut immediately(until the transfer of cord blood to the baby is complete).
【産後After childbirth】□ カンガルーケアを希望します
I would like to do kangaroo care.
□ すぐに母乳をあげたいです
I want to breastfeed immediately.
□ 母乳で育てたいです
I want to breastfeed.
□ ミルクも使いたいです
I want to use formula milk.
□赤ちゃんに、ハラルの粉ミルクの持ち込みを許可して欲しいです。
I would like to be allowed to bring in halal powdered milk for my baby.
□ 母子同室を希望します
I would like to stay in the same room with my baby during my hospitalization.
□ 母子異室(赤ちゃんと別々の部屋)を希望します
I do not want to stay in the same room with my baby during my hospitalization.
□ 大部屋を希望します
I would like to share a room with other patients.
□ 個室を希望します
I would like a private room.
□ 入院中上の子も一緒に泊まらせたいです
I would like my older child to stay with me during hospitalization.
□ 入院中シャワーに入りたいです
I would like to take showers during my hospitalization.
□ 入院中シャワーに入りたくありません
I do not want to take a shower during my hospitalization.

NPO法人Mother’s Tree Japan英 語□食べ物について希望があります
I have some requests on meals during my hospitalization.
➤宗教上の理由から(豚肉、鶏肉、牛肉及びそのエキス、卵、魚、生もの、アルコー
ルを使ったもの)は食べられません。
For religious reasons, i am not allowed to eat food like [pork, chicken, beef and their
extracts, eggs, fish, raw food, food with alcohol] .
➤()I am a vegetarian and do not eat meat, but I do (eat/drink) [fish, eggs, milk] .

ベジタリアンで肉は食べませんが 魚・卵・牛乳 は食べます□できれば栄養士さんとお話ししたいです。
I would like to speak with a nutritionist if possible.

その他の希望（自由記載）
Any other requests/comments

NPO法人Mother’s Tree Japan