MARY BETSELLIE
  • About Me
  • Goals
  • Course Work
    • Breastfeeding
    • Communications
    • Equity and Anti-Oppression in Midwifery Care
    • Homeopathy
    • Introduction to Midwifery
    • IV Skills
    • Midwife's Assistant Orientation
    • Phase One Practicum,
    • Phase Two Practicum
    • Complications of the Prenatal Period
    • MDWF - 3030 Complications of Labor Birth and Immediate Postpartum
  • Outside The Classroom
  • Resume
​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: _______________________________________
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  • About Me
  • Goals
  • Course Work
    • Breastfeeding
    • Communications
    • Equity and Anti-Oppression in Midwifery Care
    • Homeopathy
    • Introduction to Midwifery
    • IV Skills
    • Midwife's Assistant Orientation
    • Phase One Practicum,
    • Phase Two Practicum
    • Complications of the Prenatal Period
    • MDWF - 3030 Complications of Labor Birth and Immediate Postpartum
  • Outside The Classroom
  • Resume