Orange County Midwifery

Transcription

1 Orange County Midwifery Informed Consent Packet This packet contains Informed Consent forms for Orange County Midwifery. Please read each Informed Consent carefully. We also ask that you do additional research, speak with other health care professionals (physicians, chiropractors, nurses, midwives, etc.) and then speak with the father of your baby. After you have made your decision you will be asked to sign each consent form and retain a copy for your personal files. The originals will become a part of your medical chart. Failure or refusal to sign any of the above mentioned Informed Consent Forms could be considered grounds to transfer care out of Orange County Midwifery. Orange County Midwifery Lambert St. Ste. 611, Lake Forest, CA Phone: Fax:

2 Transport Informed Consent Midwifery Transport - Definitions, Protocols and Informed Consent There are a certain percentage of women planning a home birth that will risk out during pregnancy, labor or in the immediate postpartum. Risking out of a home birth means that giving birth at home is no longer safe for mother and/or baby. The majority of these circumstances represent a non-urgent transfer of care to a physician or an elective transfer to hospital-based obstetrical services. The most frequent arrangements for elective transfer of care is for the parents to drive themselves to the physician's office or hospital. Elective transfer of care is not the same as an urgent or emergency "transport". Transport is a situation in which the mother and/or baby must be transported quickly or under other special circumstances during active labor or immediately following the birth, immediate postpartum or postnatal period. Approximately 2 % of women having their first babies will require elective transfer to the hospital during labor. The most common reasons for transport at this time is a labor that does not progress normally or the need for pharmaceutical pain management or epidural anesthesia. (initial) (initial) Situations which would risk a woman out of home birth midwifery care include developing uncontrolled hypertension, placenta previa, preeclampsia, premature labor or postdates pregnancy, among others. The client may also risk out if she refuses or is unable to follow basic guidelines for the safety for her or the baby. (initial) (initial) During labor, a woman may need to be electively transferred (and occasionally urgently transported) to the hospital if she has active genital herpes outbreak, significant meconium is in the amniotic fluid, there are signs of fetal distress or signs of infection, or if there is prolonged rupture of the membranes. (initial) (initial) In the immediate postpartum the most common reason for transport is maternal hemorrhage. Aside from the transport rate for first-time mothers, the transport rates for all other reasons are actually very low, but the possibility does exist. (initial) (initial) Midwives who attend births at home have methods and protocols for handling these situations. I recognize that facilities, staff and equipment are more readily available in the hospital setting. When a problem arises at home, time is lost during transport to the hospital and such a transport delays the onset of treatment that is best administered in the hospital. The midwives do not have the equipment or training to perform the following procedures all of which can be life saving under certain circumstances: 1. Perform a forceps or vacuum extraction delivery 2. Perform a cesarean section 3. Administer emergency medication to the baby 4. Provide a blood transfusion (initial) (initial)

3 Transport Informed Consent Continued Methods of Urgent /Emergency Transport to the Hospital Transport by paramedics via ambulance is the safest way to travel to the hospital and Orange County Midwifery s first choice of urgent/emergency transport. Depending on the birth location, proximity to a hospital and the availability of EMS services, transporting by ambulance may not necessarily be the fastest method of transport. Sometimes the quickest and most straight forward method to secure hospital care is by private car. However, safety may be compromised during the trip if additional complications present themselves. If an urgent transport to the hospital is indicated, my midwife/midwives will discuss the immediate options available to us and we will mutually choose the most appropriate and effective method. In a bona fide emergency, in which there is no time for informed consent discussions, I/we will abide by our birth attendant's decision as to whether the trip should be made by ambulance or private car. In the event of any urgent/emergency transport I understand that a midwife/midwives will accompany me to the hospital. I also understand that once at the hospital I am no longer under the care or supervision of the midwives and that hospital staff may not allow them access to me. (initial) (initial) I/we have read the above information about elective hospital transfer and emergent hospital transport. We are aware of the unique risks involved in our choice to labor and give birth at home. The information provided in this document, discussions with our birth attendant and other sources of information on the relative safety of various birth settings had provided us with the basic ability to make an informed decision regarding home labor and hospital transport. Mother s Signature: Date: Partner s Signature: Date:

4 GROUP B STREP (Beta-Hemolytic Streptococcus, Group B) Group B Strep (GBS) is a type of bacteria which can be found in the genitals and/or lower intestines of 10-35% of all healthy adults. GBS is not the same bacteria as Group A Strep, which causes strep throat and other diseases. A person whose body carries GBS but does not show signs of infection is said to be colonized. GBS colonization is not contagious, and normally does not cause any problems. In fact, GBS are considered normal organisms in the human body. However, sometimes Group B Strep can invade the body and cause serious infection, referred to as Group B Strep Disease. GBS in Pregnancy Among pregnant women, 5-25% are colonized, with higher rates found among white women under age 20. Most colonized women have no problems from the GBS, but in some cases the GBS can cause infections in pregnant women in the womb, in the amniotic fluid, in the urinary tract, and following a cesarean section. Such infections can make the woman sick, and can put her unborn baby at risk. For instance, a GBS infection of the urinary tract can increase the risk of premature birth. And an infection of the womb or amniotic fluid can expose her baby to GBS. Exposure from their mothers causes 15% of newborns to be colonized with GBS, but the vast majority of them have no problems from GBS. Only 0.64 out of 1000 live births (.64.4%) result in a baby with Group B Strep Disease, or approximately 8,000 babies each year in the U.S. How Do Babies Get Sick from GBS? Typically, babies are exposed to GBS during labor and delivery. They may also be exposed after the mother s membranes rupture ( water breaks ). Babies can come in contact with GBS if the bacteria travel upward from the mother s vagina into the uterus; they may also be exposed to it while passing through the birth canal. The babies can become infected when they swallow or inhale the bacteria. There is also evidence that GBS may cross intact membranes to expose the baby while it is still in the womb. It is unclear why some babies get sick from GBS while the majority, while colonized, remain healthy. We do know that certain babies are clearly at more risk for GBS Disease than others, including premature babies, and babies with compromised immune systems. Types of Group B Strep Disease The majority (80%) of cases of GBS Disease among newborns occur in the first week of life. This is called early onset disease. Most of these babies are ill within a few hours after birth; most cases can be linked to a mother who is colonized with GBS. Babies who develop early onset disease may have one or more of the following; unstable temperature, breathing problems, grunting, fever, seizures, unusual change in behavior, stiffness, or extreme limpness. GBS Disease may also develop in infants one week to several months after birth. This is called late onset disease. About half of the cases of late onset disease can be linked to a mother colonized with GBS; in the remainder of cases, the source of infection is unknown, but may include poor hygiene practices in hospital or home. Meningitis is more common with late onset disease; the baby may develop the following signs; stiffness, limpness, inconsolable screaming, fever, refusal to eat. GBS Disease is very serious for newborns. If a baby has symptoms of infection, they need to be evaluated immediately. Blood tests, cultures, and x-rays may help determine if a baby has GBS Disease. Despite antibiotic treatment after birth, GBS Disease is fatal in 5-15% of cases, and can cause permanent neurological damage such as hearing or vision loss, varying degrees of physical or mental disabilities, and cerebral palsy, in some of those who survive. The numbers of death are small in the highest risk group, the chance of a baby dying of GBS Disease is about 1 in 3,400. But for families who are affected, the outcome is devastating. This is why it is important for you to have enough information about GBS to make a good decision for your own care.

5 GROUP B STREP (Beta-Hemolytic Streptococcus, Group B) Group B Strep continued... Assessing Risk of GBS Certain clinical risk factors, if found, put a baby at higher risk of developing GBS Disease. They are: Prenatal Risks: * Previous baby with GBS Disease * Urinary tract infection from GBS at any time during pregnancy Labor Risks: * Rupture of membranes greater than 18 hours before birth * Temperature greater than F during labor * Onset of labor prior to 37 weeks gestation Certain combinations of factors seem to increase the likelihood of a baby developing GBS Disease. It is most likely to develop in babies whose mothers are carriers of GBS (found by testing the mother) and who have one or more of the clinical risk factors listed above. Among these babies at highest risk, about 10 out of 200 (5% or 50 out of 1000) will develop GBS Disease. Babies whose mothers are GBS carriers but have no clinical risk factors are less likely to develop GBS Disease one in 200 (0.5% or 5 out of 1000). Babies whose mothers have neither risk factors nor a positive GBS culture have a very small chance of getting GBS Disease about 1 in 3000 (0.033%). Screening for Group B Strep in Pregnancy No one best way to manage GBS has been found, despite research. Currently, it remains unclear (1) who should be screened for GBS in pregnancy and (2) who should be given antibiotics prophylactically. Two different approaches are medically acceptable for managing GBS in pregnancy. American College of Obstetricians and Gynecologists & Centers for Disease Control Protocol: - Perform vaginal/rectal cultures on all women at weeks of pregnancy - Treat with intravenous (IV) antibiotics in labor if GBS positive - If GBS status is unknown at onset of labor, treat with antibiotics if any of the following risk factors are present: 1. Rupture of membranes greater than 18 hours before birth 2. Temperature greater than F during labor 3. Onset of labor prior to 37 weeks of gestation Neither of these protocols is 100% effective in eliminating GBS disease, nor have they been adequately clinically tested (BIRTH 23:1.March 1998). The protocol offered by the American Academy of Pediatrics (test at weeks, treat if positive culture and risk factors present) is no longer medically recommended. Alternatives Alternative ways of handling risk of GBS Disease in a mother whose cultures are positive include: - Using herbal and vitamin immune boosters during the pregnancy to reduce chance of GBS infection - Getting oral antibiotics from a physician during pregnancy, then retesting to see if still GBS positive - Getting an antibiotic shot from a physician, then retesting to see if still GBS positive - Using vaginal garlic suppositories and herbal/vitamin regimen, then retesting to see if still GBS positive If you decide to use antibiotics IV antibiotics in labor is the only method approved by ACOG and CDC. The dose is given every fours hours and each dose takes about thirty minutes to run in. Studies show that babies have the lowest chance of developing GBS disease when their mother is treated with antibiotics for at least four hours before birth, so the goal in treating you would be to start antibiotics at least four hours before your baby is born. Usually this requires at least two doses. The most serious risk of antibiotic treatment is the possibility that you could have an allergic reaction to the medication. Penicillin is the most effective treatment, and is definitely the

6 GROUP B STREP (Beta-Hemolytic Streptococcus, Group B) Group B Strep continued... preferred antibiotic to use. However, even in people with no known allergy to penicillin, for every 10,000 people who receive the drug, one will have a fatal allergic reaction and another 70-1,000 will have a reaction that is less serious (hives, fever, itching, vomiting, coughing and/or mild respiratory difficulty). Severe complications resulting in permanent disability can occur in the baby even when the reaction in the mother is not life threatening. Severe allergic reaction, called anaphylaxis, is a sudden systemic reaction in which the person may experience some or all of the above symptoms and then the condition progresses to include severe respiratory distress, convulsions, unconsciousness and/or death. Even in the hospital it is difficult to reverse this process; the personnel and emergency equipment needed to deal with anaphylaxis are beyond the scope of your midwives to bring to your home. Again, the chance that any given women will have a serious allergic reaction is very small, but for those affected, the outcome can be devastating. Another risk of antibiotic treatment arises from the fact that widespread use of antibiotics increases the chance that drug-resistant strains of a particular organism will develop. From a public health perspective, it is important to avoid overuse of antibiotics. GBS has become drug resistant to some antibiotics. Your Choices It is your right, and responsibility, as a pregnant woman to choose how to handle the issue of Group B Strep. Rather than imposing a particular protocol on every client, your midwives create a unique management plan for each woman based on her wishes. Please select one of the options listed below (and discussed above) as your preferred management of GBS. I do NOT wish to be cultured for GBS I DO wish to be cultured for GBS I DO wish to be cultured for GBS, and if I test positive I DO want to be treated with antibiotics in labor (requiring possible transfer of care to an OB) I Do wish to be cultured for GBS, and if I test positive I choose to do an alternative management as mentioned in this handout. I have read and understand the information on Strep B and choose the management plan indicated above. Clients Signature Date

7 Newborn Eye Prophylaxis The term eye prophylaxis refers to a substance used to prevent the eye infection Opthalmia Neonatrorum in the newborn, which can cause eye injury or blindness. California law requires health care providers to administer eye prophylaxis to each baby born, just in case the infant is at risk for developing an infection. The law does not require parents to give permission, however they can withhold permission. A baby can become infected during childbirth as it passes through the birth canal. The two known causes of Opthalmia Neonatorum are the sexually transmitted diseases Gonorrhea and Chlamydia. A vaginal culture can be taken during pregnancy to help determine if you carry either Gonorrhea or Chlamydia. However, a negative culture is no guarantee that you do not have one of the diseases, as they are often difficult to detect. If the baby does become infected with Gonorrhea or Chlamydia and is not treated, permanent eye damage, and even blindness, can result. The most common treatment of Opthalmia Neonatorum is an antibiotic ointment, Erythromycin. The law requires the attendant to place a small amount of ointment in the baby s eyes within two hours of the baby s birth. Another approved treatment is tetracycline ointment, and rarely, 1% silver nitrate solution. The risks of all treatments are obscured vision for several hours, and reaction to the antibiotic. Because the antibiotic is administered locally in an ointment form, the risk of a negative reaction is extremely low. Orange County Midwifery does not routinely carry any eye prophylactic treatment. If you choose to have your baby given eye prophylactic treatment you will need to notify us by your 35th week so we can arrange to have it available for your birth. The cost of administering eye treatment to the baby is $ As a parent you have the right to refuse permission for prophylactic treatment of your newborn. I/We choose the following option for our baby: Give permission to treat the baby per California Health requirements and agree to arrange and pay for the medication to have at the time of birth for the midwives to administer Run a vaginal culture for gonorrhea and Chlamydia; treat the mother and baby if culture is positive Decline permission to treat the baby I, the undersigned parent, have received this information sheet. I have read and understand the information enclosed and choose the option indicated above for administration of eye prophylaxis to my newborn. Mother s Signature Date: Partner s Signature Date:

8 Newborn Vitamin K Vitamin K is a necessary part of 4 of the 12 clotting factors in the blood. All of the factors interact to form a clot, so a deficiency in any one can cause bleeding disorders. We produce Vitamin K in the gut using the food we eat and substances in the body. A newborn has relatively low amounts of Vitamin K, compared to older babies, children and adults. The production of Vitamin K depends, in part, on a fully functioning GI tract. In newborns, full digestion does not happen at birth and depends on whether the baby is breast or formula fed. Also, Vitamin K does not cross the placenta at a high volume. For these reasons, the newborn naturally has a lag time before Vitamin K production begins usually 6-7 days. Why is Vitamin K Routinely Given to Newborns? Vitamin K is given to prevent HDN (Hemorrhagic Disease of the Newborn), also known as Vitamin K Deficiency Bleeding (VKDB). This is a very rare disease where the baby suffers from very prolonged blood clotting times, leading to unexplained bleeding and/or bruising. It is a serious disease, which can cause severe brain damage or death in about 1/3 of cases. Incidence is 0.01% to 1.5% of those who have not received Vitamin K, with life threatening incidence estimated to be 5-50 per 100,000 if no Vitamin K is given. This wide range is due to different feeding patterns and risk factors. There are three types of HDN 1) Early Onset: very rare. Occurs within 24 hours of birth. Usually seen in babies of women on medication such as anticonvulsants, anticoagulants, or anti-tuberculosis meds. 2) Classic: occurs during the first week after birth. Preventable by giving Vitamin K. If symptoms of the disease are present, the baby is likely to recover if it receives Vitamin K. 3) Late Onset: most frequent type. Occurs after the baby s first week, usually between 3-8 weeks. Often occurs in breastfed babies who didn t receive Vitamin K at birth. Diagnosis is confirmed when a bleeding infant has a prolonged prothrombin time (PT) together with a normal fibrinogen level and platelet count. Rapid correction of the PT and or cessation of bleeding after Vitamin K administration confirms the diagnosis. Baby s at High Risk for Developing HDN - Premature babies - Babies who had traumatic deliveries (including shoulder dystocia, vacuum extractor, forceps) - Babies of mother s who used medications, including barbiturates or anti-seizure meds - Babies who suffered oxygen deprivation from placental abruption or previa - Babies receiving antibiotic treatment - Babies having surgery, including circumcision performed before the 8th day of life - Breastfed babies who didn't receive Vitamin K at birth. This is because breast milk, unlike formula which has extra vitamins added, is relatively low in Vitamin K

9 Newborn Vitamin K Newborn Vitamin K Cont Signs of HDN External visible bleeding, evidenced by skin bruising or blood seepage from any body opening or the umbilical stump may be the first warning signs of HDN and can quickly lead to serious internal bleeding. 30% to 60% of the time internal unseen bleeding is from fragile capillaries in the brain and often results in severe delayed development of the infants, or even death. If such bruising or bleeding occurs, a health care professional needs to be contacted right away. Administration of Vitamin K is needed swiftly before seizures begin. Sometimes internal bleeding occurs without visible outwards signs. How is Vitamin K Administered? In hospitals, based on recommendation of the American Association of Pediatrics, Vitamin K is given as an intramuscular injection of 1.0 mg in the baby s thigh during the first two hours after birth. This has been proven to decrease the incidence of HDN after only one dose. An alternative to the injectable Vitamin K is giving the vitamin by mouth. However, just one dose of oral Vitamin K does not prevent Late Onset HDN. Currently the American Association of Pediatrics recommends three oral doses of 2 mg each. Is Routine Use of Vitamin K with Newborns Necessary and Safe? The vast majority of medical literature strongly recommends giving all babies some sort of Vitamin K at birth. The United Kingdom currently only gives Vitamin K to babies who are premature, low birth weight, or had traumatic births. In the early 1990 s, several researchers reported that intramuscular injections of Vitamin K was associated with increased risk of childhood cancer, particularly lymphoblastic leukemia. Other studies have failed to confirm those finding. Jean Golding, a Vitamin K researcher, poses that a relative deficiency in Vitamin K during the critical early growth period of a newborn may protect vulnerable tissues from mutagenesis and cancer risk at a time of rapid cell multiplication. No negative effects of Vitamin K have been proven. Alternative Treatments In her book, Holistic Midwifery, Anne Frye, CPM, suggests the following alternatives to IM Vitamin K. None of these have been medically tested for effectiveness: - Prenatal supplementation of Mom beginning 4-6 weeks before term with 3 grams alfalfa daily and continue through breastfeeding. - Oral Vitamin K drops - Shepherd s Purse tincture, which contains clotting factor precursors and Vitamin K (3 drops to infant by mouth)

10 Newborn Vitamin K Newborn Vitamin K Cont California Requirements California law requires health care providers to administer Vitamin K to each baby they deliver just in case the baby should develop HDN, unless the baby s parents withhold permission. As a parent you have the right to decide which treatment you will or will not permit to be administered to your newborn. Your options include: Administer one dose of injectable Vitamin K at birth. (Available with Orange County Midwifery for $15.00) Administer 3 doses of oral Vitamin K (one at birth, one at one week and one at 3 weeks). I understand that Orange County Midwifery does not routinely carry oral Vitamin K and I must order it by the 36th week of birth. You can purchase at in our birth kit under optional supplies. Decline permission to treat the baby with Vitamin K I, the undersigned parent, have received this information sheet. I have read and understand the information enclosed and choose the option indicated above for administration of Vitamin K to my newborn. Mother s Signature Date Partner s Signature Date

11 Newborn Physician Exam Newborn Physician Exam I/we, the undersigned parents, clearly understand that the midwives will perform an initial newborn exam after the birth of our baby but that this exam should not substitute the newborn exam made by a licensed physician. We also understand that Orange County Midwifery protocols state that we are to take our newborn baby to the pediatrician or family practice MD as directed by our chosen doctor. We clearly understand that the midwives are not medical doctors. Mother s Signature Date Partner s Signature Date

12 Waterbirth Orange County Midwifery Information and Suggestions for Water Birth Definition: Use of deep water immersion in Tub/Pool for labor and/or birth Benefits for Mother: (Listed benefits reflect correct water temperatures as listed below) Pain relief Increase in endorphins and Relaxin and decrease in Cortisol levels Water waves and movements stimulate skin receptors to trigger Oxytocin release Relaxation of pelvic floor, better dilation and retraction of the cervix Hemoglobin stability resulting in decreased postpartum hemorrhage Intensified uptake of oxygen by uterine vessels resulting in more stable fetal heart rate Improved insulin metabolism Pressure on fetal head minimized Labor shortened Mother has better control of providing her own perineal support and pushing effort resulting in less perineal tearing and mother-assisted birth Placenta: Improves blood flow to the placenta, increases efficiency of uterine contractions which speeds separation of the placenta and reduces blood loss and possible postpartum hemorrhage Benefits for Baby: (Listed benefits reflect correct water temperatures as listed below) Less cerebral palsy resulting from a better chemical response between calcium and sodium and reduced demands on supply. Water birth results in better neurocorticol maturation resulting in better sense of balance, symmetry, muscle coordination and development Babies become conscious of their births and may talk about their births for 2-4 years Indications: Orange County Midwifery recommends water birth for the following women. 1. Mother desires water birth 2. Women with low level preeclampsia or high blood pressure 3. Women carrying large babies or history of CPD (baby didn t fit through pelvis) 4. Women needing Pain Relief 5. Women with a previous cesarean surgery - VBAC 6. Women with poorly healed episiotomy scars 7. Babies in the Posterior presentation (we encourage mother to belly dance in water) 8. Babies who have a lower range of heart tones during pregnancy 9. Women who are GBS positive with no fever 10. Women who have rupture of membranes with meconium staining during active labor

13 Waterbirth Risks or Problems associated with water birth: Hyperthermia: water temperature too hot ( F) 1. Mother exhibits signs such as sweating, flushing, increased blood pressure, respiration and pulse, dehydration 2. Increased heart rate in baby (tachycardia) 3. Placenta: Increases delay of placental separation and postpartum bleeding/hemorrhage Hypothermia: water temperature too cold (77-86 F) 1. Mother exhibits signs such as shivering, stalled labor, premature exhaustion, lower heart rate, lower core body temperature leads to peripheral vasoconstriction, slow delivery of placenta 2. Decreased movements in baby and slowing of the fetal heart rate 3. Baby may have difficulty beginning to breath and show signs of hypoglycemia after birth Contraindications: 1. Maternal Infections with fever (influenza, viral infections, etc) 2. Fetal heart rate irregularities during first stage labor Water Temperatures Guidelines: The following guidelines are for keeping the proper temperature of the water during the various stages of labor, birth and postpartum. The benefits of water birth are based on keeping with these guidelines. Water temperature should decrease as labor progresses. Mother should use the lowest temperature she is comfortable with. Early Labor: (0-3 cm dilation) water temp should be between 95-98F (35-37C) warmth stimulates labor but can also make prodromal or false labor stop Active Labor: (5-10 cm dilation) temperature of water should fall to 84-96F (30-35C) as mother desires. The cooler the water during this stage, the better the progression of labor. If labor seems too hard or contractions too close or too strong, then cool water 2nd stage through birth and delivery of placenta: cooler water for optimum fetal movements After delivery of the placenta, warm water again to 95+ Breastfeeding in water, then warm water again to 95F + For women with thyroid diseases, obesity or toxemia, use cooler water temperatures Laboring in Water: 1. In early labor (from 0-3 cm) Mother can be in tub for 2 hours and then needs to get out for 1 ½ hours until labor progresses 2. Once in active labor (5 cm or more) can be in water continuously until baby is born 3. Mother should get out of tub to urinate at least every hour 4. Mother should drink plenty of fresh water, juice, teas or sports drinks during first stage to prevent thirst

14 Waterbirth 5. During second stage, drink ONLY fresh water after every contraction (no teas or juices) 6. If mother has swelling, then offer water after each contraction Delivery of Baby in Water 1. We recommend Mother Assisted birth with midwife/s observing mother and offering support and suggestions as needed. We prefer the hand s off method and will intervene only when necessary or desired. 2. Mother can provide perineal support if she desires as head emerges. Use slow pushing and/or grunting at crowning of baby s head 3. Midwife will check for cord around the baby s neck and watch for shoulder rotation as baby born to it s navel 4. Mother should make eye to eye contact with her baby once the head is out and as it is being born as this releases the hormone prolactin 5. Wait for next contraction to birth rest of body to feet don t need to hurry 6. Watch baby for the expulsion of lung fluid and postural reflex, and once these occur, then bring baby up out of water to mothers left breast. 7. Midwives will observe mother and baby and get a water birth apgar score, provide care as needed 8. The Placenta can be delivered either into the water or with mother standing and into bowl or mother and baby can get out of tub to deliver placenta 10. Talk and Nurse your baby and make sure that the baby does not slip below the water or get a mouthful of water I understand the risks and benefits of Water Birth and choose to use labor and if preferred, deliver in water. (initial) (initial) Resources: Cornelia Enning, Aquamidwife in Muhlacker, Germany Lecture notes from Waterbirth Congress April 22-25, 2004 Chicago Hyatt Regency Oak Brook Lecture notes from Midwifery Today Conference, Bad Wildbad, Germany Waterbirth Symposium in Chicago, Il, Habammen-Praxis, Waterbirth midwifery, cptr 8, page 48, Stuttgart 2003 Wassergebertsfilke, chpt 23, p126 Stuttgart 2003 Kneipp 1886

15 Orange County Midwifery Informed Consent for Water Birth I, have requested to participate in a water birth which means that I may choose to labor and possibly deliver my baby in a tub of warm water. I understand that the benefits reported with water birth include: 1. An increased sense of relaxation 2. An increased sense of reduced pain 3. Possible decrease in the length of labor 4. Decrease in the need for an episiotomy I understand that the risks associated with water birth may include: 1. Possible undetected problem for me or my baby during labor 2. Possible dehydration 3. Possible elevated temperature, which could cause the baby's heartbeat to go up 4. Remote possibility of infection for myself or the baby I agree to careful evaluation of myself and my baby during labor and after birth to prevent or minimize the risks identified above. I understand that safety of myself and my baby are the primary criteria for making recommendations and decisions about my care. I understand that some problems for my baby or myself may require me to leave the tub and/or to deliver in the bed rather than the tub and I agree to follow the instructions of the midwives in treating actual or suspected problems and safeguarding me and my baby's health. Mother s Signature Date Partner s Signature Date

16 Agreement for Borrowing a Water Birth Tub The following agreement represents an agreement between Lindsey Meehleis &/or any representative associated with Orange County Midwifery and. (Client s name) 1. I do hereby acknowledge and agree that I am borrowing a water birth tub identified in this contract. There is no charge to client unless tub is damaged and needs to be replaced. 2. I acknowledge that the borrow water birth tub is specifically limited to indoor use. 3. I understand that the Lindsey Meehleis &/or any representative associated with Orange County Midwifery is not responsible for setting up or taking down the water birth tub. 4. I agree, and take full responsibility for the manner in and purpose for which the water birth tub is used. I understand that I am responsible for making sure the temperature of tub is an ideal temperature to give birth in as discussed above. 5. I agree to return the water birth tub to Lindsey Meehleis &/or any representative associated with Orange County Midwifery undamaged and thoroughly cleaned. 6. I agree to pay a $150 if, in the unlikely event, the water birth tub is damaged. 7. I agree to release Lindsey Meehleis &/or any representative associated with Orange County Midwifery and affiliated manufacturers from any and all responsibility or liability for maternal complications, infant mortality or morbidity, or injury to any or all persons in connection with the use of said water birth tub that may occur before, during, and/or after labor and/or birth in the water birth tub. I also release Lindsey Meehleis &/or any representative associated with Orange County Midwifery from any monetary damage that may be caused by a damaged tub and the unlikely event that water damage would occur to my property. STANDARD WARNINGS AND SAFEGUARDS for the safe operation and use of a water birth tub. CAUTION: Do not use alone. CAUTION: Unsupervised use by children is prohibited. Never leave children unattended without adult supervision in the vicinity of the filled water birth tub. CAUTION: Enter and exit slowly. CAUTION: Keep all breakable objects out of the area. CAUTION: Keep all sharp foreign objects out of the water birth tub to protect against punctures or other damage. CAUTION: DO NOT run any of the cords under any portion of the water birth tub. This may result in a pinched or damaged cord presenting a potential electric shock hazard. Mother s Signature Date Partner s Signature Date