BIRTH and EMEGENCY PLAN

I will be attended by ______________________________ WARNING SIGNS DURING PREGNANCY HOME BASED

Doctor/Nurse/Midwife
I plan to deliver at ________________________________ o SWELLING OF THE LEGS, HANDS AND/OR FACE MOTHERS RECORD
(Hospital/RHU/Clinic/BHS) o SEVERE HEADACHE, DIZZINESS, BLURRING OF
ALWAYS BRING THIS CARD WHEN YOU VISIT A HEALTH FACILITY
This is a PhilHealth Accredited Facility Yes No VISION
o VAGINAL BLEEDING OR VAGINAL SPOTTING
I have a PhilHealth card Personal Savings NAME:
o PALLOR OR ANEMIA
o FEVER AND CHILLS ADDRESS:
Available transport is _______________________. o VOMITING
I have contacted _______________________ to bring me o FAST OR DIFFICULTY OF BREATHING
to the health facility. PHILHEALTH No. BLOOD TYPE:
o SEVERE ABDOMINAL PAIN
I will be accompanied by __________________________.
o VAGINAL DISCHARGE AND/OR GENITAL SORES
AGE: DATE OF BIRTH: HT:
In case of blood transfusion, my possible blood donors are: o PAINFUL URINATION
1. _________________________ ___________________ o WATERY VAGINAL DISCHARGE
2. _________________________ ___________________ o CONVULSIONS OR LOSS OF CONSCIOUSNESS LMP: EDC: GP:
3. _________________________ ___________________ o ABSENCE OF/ REDUCED FETAL MOVEMENTS
In case of complications, I will be referred right away to: (less than 10 kicks in 12 hours in the second half of
Physician: ______________________________________ pregnancy)
Referral Hospital: ________________________________ DATE TETANUS TOXOID GIVEN:
Tel. No./ Cell No. ________________________________ 1 2 3 4 5
HELPFUL TIPS TO REMEMBER

Eat a balanced diet and increase intake of food for

energy (carbohydrates, protein, Vitamin A, Folic PRESENT HEALTH PROBLEMS
YES/NO FAMILY
Acid, and other nutrients) HISTORY
OBSTETRICAL HISTORY Practice oral and personal hygiene. Visit dentist HEALTH PROBLEMS/ILLNESS/UNHEALTHY
NO YES NO YES
LIFESTYLE
regularly.
NUMBER OF PREVIOUS 1 2 3 4+ Start breast care in preparation for breastfeeding. TUBERCULOSIS (14DAYS + OF
PREGNANCIES Do not resort to self medication to avoid harmful COUGH)
effects on pregnancy. HEART DISEASE
PREVIOUS CAESARIAN SECTION NO YES
Make sure to receive Tetanus Toxoid immunization HYPERTENSION
3 CONSECUTIVE MISCARRIAGES NO YES for protection of both mother and baby. GOITER
Prepare for possible emergency (money, blood DIABETES
STILLBIRTH NO YES BRONCHIAL ASTHMA
donor, transportation, newborn screening, Hep B,
and hearing, and other necessities) URINARY TRACT INFECTION
POST-PARTUM HEMORRHAGE NO YES
SMOKING
ALCOHOL INTAKE