MATERNIDAD LA LUZ, THE BIRTH PLACE, INC.

MATERNIDAD LA LUZ, THE BIRTH PLACE, INC. is a Texas state licensed cmmunity birth center, ffering yu and yur family a place t have a safe, supprtive, and natural birth. Since 1987, ver 12,500 babies have been brn at ur birth center with skilled, prfessinal midwives licensed by the State f Texas. Maternidad La Luz is als a natinally accredited schl f midiwfery that has graduated ver 500 midwives wh are prviding midwifery care t wmen all ver the wrld. WHAT IS A MIDWIFE? The Texas Midwifery Bard defines midwifery as the practice f prviding the necessary supervisin, care, and advice t a wman during nrmal pregnancy, labr, and the pstpartum perid; cnducting a nrmal delivery f a child; and prviding nrmal newbrn care. Midwives are peple wh practice midwifery and have met the Texas licensing requirements established by the midwifery bard rules. Midwifery is a lng-standing traditin in Texas health care because midwives: Offer a safe, mre ecnmic alternative t hspital birth, Prvide mre persnalized and respectful care, Wrk in partnership with their clients, Are less dependent n technlgy, and Prvide family-centered care. Are midwives safe? Wrldwide research indicates that utcmes fr midwife-attended births, including planned ut-f-hspital births, are as gd as r better than utcmes fr physiciansupervised hspital deliveries. Making the right chice fr a birth place is an imprtant decisin. We hpe that yu and yur family will take the time t lk at ur birth center and ask questins. We lk frward t sharing this special time with yu. THE MIDWIVES MODEL OF CARE Maternidad La Luz intregrates the principles f the Midwives Mdel f Care in all aspects f pregnancy, birth and pstpartum care. We recgnize that pregnancy and childbirth are nrmal, healthy life prcesses, nt diseases. The Midwives Mdel f Care includes: Mnitring the physical, psychlgical, and scial well-being f the mther thrughut the childbearing cycle; Prviding the mther with individualized educatin, cunseling, and prenatal care, cntinuus hands-n assistance during labr and birth, and pstpartum supprt; Minimizing technlgical interventins; and Identifying and referring wmen wh require bstetrical attentin. INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 1 f 6

The Midwives Mdel f Care results in less chance f cmplicatins, fewer interventins, and a healthier birth fr yu and fr yur baby. The applicatin f this wman-centered mdel f care has been prven t reduce the incidence f birth injury, trauma, and cesarean sectin. WHAT TO EXPECT FROM YOUR CARE AT MATERNIDAD LA LUZ At Maternidad La Luz we value the right f every wman t experience birth feeling safe, empwered, and nurtured. We encurage yu t have yur family r friends with yu thrughut yur pregnancy, labr, and birth. Their supprt and invlvement will help yu t feel mre cmfrtable and relaxed. Initial Appintment Yur initial appintment gives us a chance t get acquainted and t discuss yur upcming birth. It includes a review f yur medical and bstetrical histry, a physical examinatin, initial labratry wrk, current health assessment, a pap smear, and gnrrhea and chlamydia screens. Sme f these may be spread ver yur first several appintments, depending n the stage f yur pregnancy. Prenatal Care During prenatal appintments, a midwife mnitrs yu and yur baby, and prvides an pprtunity t address questins r cncerns that yu may have. Appintments will include mnitring f maternal weight gain, bld pressure, and uterine grwth; determinatin f fetal psitin and heart rate; and screening fr early detectin f cmplicatins and infectins. Childbirth educatin plays an imprtant rle in midwifery care. Maternidad La Luz ffers classes and vides t prepare yu and yur family fr yur birth experience. Classes and vides include: nutritin and exercise, pregnancy, stages f labr, psitins fr labr, breastfeeding, and pstpartum care f mther and baby. Labr And Birth During yur labr and birth, the midwife will prvide persnalized physical and emtinal supprt. She will mnitr yur prgress, assist yu with relaxatin and breathing techniques, and assess yu and yur baby fr pssible cmplicatins. At Maternidad La Luz we use n pain medicatin during labr and childbirth, but use natural methds t assist yu in having a satisfying birth experience. After the birth, yu and yur baby will stay at the center fr apprximately 6 hurs. During this time the midwife will assess yu and yur newbrn, administer infant eye prphylaxis, perfrm the newbrn screen (heel stick) t screen fr certain serius metablic and hematlgical disrders, and prvide breastfeeding supprt. We will als prepare the dcuments necessary fr yur baby s Texas birth certificate. Hmebirth Smetimes Maternidad La Luz is able t prvide hmebirth services in Texas and New Mexic. If yu wish t cnsider this ptin, please discuss it with ne f the staff midwives. Pstpartum There are five r six pstpartum visits scheduled. At these visits we ensure that yu and yur baby are ding well and help with breastfeeding if needed. At yur 5-day pstpartum appintment, yur baby s birth certificate will be ready fr yu t review and sign. At yur 12-day pstpartum appintment, we will d a secnd newbrn screen. At yur 6-week pstpartum visit yu may have a secnd Pap exam if yu wish. INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 2 f 6

CLIENT S RIGHTS AND RESPONSIBILITIES Althugh there is a standard f care applied t every client, yu will be evaluated and cared fr apprpriately as an individual by the staff at Maternidad La Luz. As a client f Maternidad La Luz, it is yur right and respnsibility t understand all f the care that is ffered t yu. Yu have the right t questin and/r decline any service r test that is ffered. Hwever, declining certain services r tests may make yu ineligible t cntinue receiving care at Maternidad La Luz. Yu have the respnsibility t take care f yurself t the best f yur ability thrugh gd nutritin, exercise, rest, and cming t yur scheduled appintments and childbirth educatin. IMPORTANT CLIENT INFORMATION In rder t be accepted as a client at the center yu must meet the requirements set ut by the Texas Department f State Health Services. This dcument defines ur scpe f practice. These rules help prtect yu and yur baby. The law may require that yu have a cnsultatin with a Texas licensed physician r be referred t a hspital fr certain cnditins. Maternidad La Luz cannt guarantee that yur baby will be brn at the center r in the United States. In an emergency, yu will be transprted t the nearest hspital, usually University Medical Center (UMC). We make every attempt t accmpany ur clients t the hspital in the event f a transprt. If transprted, financial arrangements with the hspital are the respnsibility f the client. The hspital staff will evaluate yu and decide if need t be admitted r if yu may be permitted t return t the care f Maternidad La Luz r yur physician. Maternidad La Luz des nt allw vides f births. We will help yu with still phts f yur baby s birth if yu bring yur wn camera. Maternidad La Luz may need t cnsult by phne r in writing with a health care prvider regarding yu r yur baby. This may include yur persnal physician r a health care prvider that we wrk with. Neither Maternidad La Luz nr its staff carries liability r malpractice insurance. By signing belw I acknwledge that I have read and understand the cntents f this dcument, and that I have had the pprtunity t discuss it with the midwife. All f my questins cncerning this dcument have been answered t my satisfactin. Signature Date INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 3 f 6

Payment Agreement I agree t pay Maternidad La Luz $695.00 fr midwifery services in payments, r $595.00 if paid in full tday. I understand that I may begin my care with a $150.00 depsit. I understand that I am expected t pay in full by the 36 th week f my pregnancy. The fee fr a hme birth is $1250.00. I understand that if I am in labr when I cme fr my initial appintment, I will pay $800.00 in full. The fee includes the fllwing: The fee des NOT include the fllwing: Initial appintment fee Additinal labratry fees REFUND POLICY Prenatal appintments Labratry tests (bld wrk, Pap smear, gnrrhea & chlamydia tests, plasma glucse test) Nutritinal cunseling Childbirth educatin Labr and birth, including water birth and VBAC Immediate pstpartum care Pstpartum appintments Preparatin f birth certificate if baby is brn at MLL Any cnsultatin with a physician Hspital csts Ambulance csts Pediatrician csts Sngrams Suturing, if needed ($50.00-$100.00) RhGAM, if needed ($95.00) Baby crd bld sample if yu are Rh negative ($25.00) IV therapy, if needed ($25.00) If yu are transprted befre the baby is brn, r fr any reasn yu d nt birth at Maternidad La Luz, yu are still required t pay fr the prenatal care yu have received. The charges will be calculated in the fllwing manner. $300.00 is the registratin and initial appintment fee. This mney will nt be refunded under any circumstances. $35.00 is charged fr each additinal prenatal appintment and each labr check. $150.00 Facility fee is charged if yu are admitted in labr. This fee is nt refundable. The sum ttal f the abve fees will be subtracted frm the amunt yu have paid. Fr example: Registratin fee 2PN appintments 1 Labr check Facility Fee $300.00 + 70.00 +35.00 +150.00 555.00 Ttal amunt paid Minus care received Refund $695.00 555.00 $140.00 If yu have had several prenatal appintments, it is pssible that yu will nt get a refund. If, fr whatever reasn, yu r yur baby needs t be transprted t a hspital r clinic after the birth, there will be NO REFUND f yur mney. Hwever, yu and yur baby are still entitled t pstpartum appintments at n additinal cst. I,, have read and understand this plicy and have had an pprtunity t have my questins answered. Signature Date INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 4 f 6

TEXAS DEPARTMENT OF STATE HEALTH SERVICES (DSHS) 1100 WEST 49 th STREET AUSTIN, TEXAS 78756-3199 (512) 834-4523 r (800) 942-5540 Eduard J. Sanchez, M.D., M.P.H., Cmmissiner INFORMED CHOICE AND DISCLOSURE STATEMENT Accrding t Texas Law, Texas Occupatins Cde Ch. 203, the Midwife is required by the law t disclse in ral and written frm t a prspective client the limitatins f the skills and practices f the midwife. The Infrmed Chice and Disclsure Statement meets these legal requirements. Each midwife may als expand the dcument int a mre extensive infrmatin chice agreement reflecting details f her/his practice. A. Accrding t the Midwifery Law, the midwife: 1. Assists nly with nrmal childbirth except in an emergency situatin that pses an immediate threat t the life f the mther r newbrn. 2. Encurages each client t seek prenatal, pstpartum, and newbrn care if nt ffered as part f the midwife s service. 3. Advises each client t seek medical care if the client develps signs r symptms f a cmplicatin related t pregnancy. 4. Des nt use frceps r surgical instruments fr any prcedure ther than cutting the umbilical crd r prviding emergency first aid during delivery. 5. Des nt remve the placenta by invasive techniques. 6. Des nt advance r retard labr r delivery by using medicines r mechanical devices. 7. Des nt administer a prescriptin drug except under the supervisin f a physician licensed by the State f Texas, with the exceptin f xygen and state apprved prphylaxis t prevent blindness f the infant. 8. Des nt knwingly r intentinally falsify r make false statements n a birth certificate applicatin. (This ffense is prsecutable as a felny f the third degree.) 9. Des nt use prfessinal titles ther than Licensed Midwife r Certified Prfessinal Midwife (CPM) if certified by NARM. 10. Has explained t the client all the ther legal requirements which are applicable t the midwife s practice: The newbrn screening law requires every newbrn t receive testing fr certain diseases. A midwife is trained t d cmpulsry newbrn screening, r has made arrangements fr it t be dne by an apprpriate health care facility r physician. A newbrn baby must receive eye prphylaxis within tw hurs f birth t prevent pssible blindness frm infectin. A serlgy bld test fr syphilis and Hepatitis B is necessary during pregnancy and n admissin fr birth. A serlgy bld test fr HIV is necessary at the first prenatal visit and during the third trimester, unless the mther bjects. The result f the test is cnfidential, nt annymus. Cmmunicable diseases must be reprted. Registratin is necessary fr bth births and deaths. Cmpliance with prvisins f the Dangerus Drug Act and the Cntrlled Substances Act is necessary, and ther laws as applicable. 11. Has made this frm available t the client in English and Spanish. 12. Has made the statistics specified by the Texas Midwifery Bard available t each client. INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 5 f 6

B. Shuld the client have a cmplaint abut the care she receives frm the midwife, she may cntact the DSHS Midwifery Prgram, rally r in writing: Texas Department f State Health Services Midwifery Prgram MC 1982 Prfessinal Licensing & Certificatin Unit 1100 West 49 th Street Austin, TX 78756 (512) 834-4523 r 1(800) 942-5540 A cpy f the cmplaint frm is available n the Texas Midwifery Bard website at: http://www.dshs.state.tx.us/midwife/ C. The midwives must als supply the client with the fllwing infrmatin: The expiratin date f the midwife s license is March 2011. All midwives at Maternidad La Luz are certified in CPR and nenatal resuscitatin. Medical arrangement: A licensed staff midwife will assess the client and her baby, and make the apprpriate arrangements fr cnsult. If it is an emergency 911 will be activated and they will make the apprpriate transprt. Educatin. All Maternidad La Luz midwives: have attended and passed an apprved midwifery training curse are licensed in the State f Texas participate in cntinuing educatin wrk in a Texas licensed birth center D. Midwifery Experience at Maternidad La Luz The center pened in March 1987: We have been practicing midwifery fr 24 years. We have attended ver 12,500 births as primary care givers. All f the abve requirements and acts in sectins A D have been disclsed t me rally and in written frm and I understand them. Signature Date INFO RMA TION A BO UT MA TERNIDA D LA LUZ P age 6 f 6