Emergency Plan
Birth giver name: ____________________________________________________
Planned place of delivery: _____________________________________________
This is an outline of the planned referrals during the prenatal period should a risk factor occur which requires consultation with or transfer of primary responsibility for maternity/ neonatal care to a licensed health care provider or which requires maternal or infant transport to a hospital capable of providing necessary or emergency services including cesarean section.
● Prenatal consultation, but not transfer of care:
● Planned pediatric care provider:
● Conditions where care is transferred during the prenatal period to another provider:
● Should intrapartum, but non-emergent, transport of the mother be required with the birth-givers care transferred to physician on call:
Name of facility of first choice _______________________________________________________
Number of miles to the facility of first choice: ______________
Address facility of first choice ________________________________________________________
● Should the newborn need urgent, but non-emergent care:
Name of facility of first choice __________________________________________________
Number of miles to the facility of first choice: ______________
Address facility of first choice ________________________________________________________
● Closest hospital for emergent situations, with the mother’s care transferred to OB on call and/or infant’s care transferred to Pediatrician/Neonatologist on call:
Name of facility ___________________________Number of miles to the facility ______________
Address facility ________________________________________________________
Birth giver signature: ___________________________
Midwife signature: _____________________________
Date: _______________________________________
Birth giver name: ____________________________________________________
Planned place of delivery: _____________________________________________
This is an outline of the planned referrals during the prenatal period should a risk factor occur which requires consultation with or transfer of primary responsibility for maternity/ neonatal care to a licensed health care provider or which requires maternal or infant transport to a hospital capable of providing necessary or emergency services including cesarean section.
● Prenatal consultation, but not transfer of care:
● Planned pediatric care provider:
● Conditions where care is transferred during the prenatal period to another provider:
● Should intrapartum, but non-emergent, transport of the mother be required with the birth-givers care transferred to physician on call:
Name of facility of first choice _______________________________________________________
Number of miles to the facility of first choice: ______________
Address facility of first choice ________________________________________________________
● Should the newborn need urgent, but non-emergent care:
Name of facility of first choice __________________________________________________
Number of miles to the facility of first choice: ______________
Address facility of first choice ________________________________________________________
● Closest hospital for emergent situations, with the mother’s care transferred to OB on call and/or infant’s care transferred to Pediatrician/Neonatologist on call:
Name of facility ___________________________Number of miles to the facility ______________
Address facility ________________________________________________________
Birth giver signature: ___________________________
Midwife signature: _____________________________
Date: _______________________________________