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Informed Consent for Homebirth

My name is Meg Glascoff (Brenda Margaret Glascoff Rodenbusch) and I practice as a Certified Professional Midwife. The CPM is a national certification, recognized in 26 US states and many locations internationally. I am also a graduate of the Association of Texas Midwives Midwifery Training Program, an intensive 2.5 year academic program that prepares student midwives for the demands of the profession. I am also licensed through the Texas Midwifery Board to practice midwifery in the State of Texas. Obtaining this license involved completing a 3 year apprenticeship with a local CPM, performing prenatals and observing births, and managing labors and births as primary under supervision. Additionally, I successfully passed an eighthour written exam (the NARM exam). I am also certified in Neonatal Resuscitation and CPR for the Professional Rescuer. I complete a minimum of 20 hours continuing education every 2 years to maintain my certifications. My license number with the State of Texas is #99145, and I am a member in good standing of the Association of Texas Midwives. My Texas license expires in March of 2014 and will be renewed at that time. My CPR certification expires: April 2013 My Neonatal Resuscitation certification expires: September 2013 I have been attending births since 2009. As of _September 2012_, I have attended __165_______ home and hospital births, ___25________ as primary care giver. Of the home births I have attended as primary, my transport rate is currently __8%____births and my C-section rate is _4%____ births. My belief is that every woman has the right to choose where and with whom she has her baby. However, as a Licensed Midwife, I must abide by state regulations, which restrict my practice in a number of ways. Should your pregnancy fall outside of my realm of practice at any point, I will do my best to help you make alternative plans for the remainder of your pregnancy and birth. All births, regardless of the setting (hospital, birthing center or home), carry a certain degree of risk. Even with low risk pregnancies and births, complications can arise. Generally, when complications do arise there is ample time to transport to the hospital. Occasionally, complications must be dealt with at home. Some complications that I have personally experienced include, but are not limited to, prolonged labor, dehydration, retained placenta, postpartum hemorrhage, shoulder dystocia, face presentation, cord prolapse, psychological dystocia, presence of meconium, birth defects, prematurity, fetal distress, meconium aspiration syndrome, and respiratory distress. Emergency medical equipment that I carry with me to a birth includes: an oxygen tank and masks for mother and baby, Pitocin, Methergine (with standing orders) and oxytocic herbs to manage postpartum hemorrhage, and my own skill and experience. While I will do my best to help plan a strategy for back up care for mother and baby and for transport care to medical facilities in case of emergency, be advised that the vast majority of health practitioners do not support homebirth. However, the Emergency Medical Treatment and Labor Act (EMTALA) mandates that hospitals may not refuse emergency treatment to pregnant women or women in labor. Should a transport occur, you will not know which physician will care for you or your baby. I cannot guarantee what type of reception you will receive from the hospital staff or physicians. We are lucky, however, to live in a city where St. David's Hospital exists. Our transports to their facility are generally smooth and we are most often received with grace, competency, and kindness. In the event of a transport, the on-call OB at the hospital will become your primary care provider. I will then step into a labor support position. In the event of either a complication or at my own discretion, if I determine that the well-being of mother or baby is at risk, I will recommend transport to the hospital that I feel will best be able to meet your needs. Please be advised that I expect the cooperation of both mother and father if transport becomes necessary. If transport is refused, I may be forced to call an ambulance to stabilize mother and/or baby. Upon arrival of the ambulance, I will turn care of mother and baby over to the paramedics.

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My main goal is a safe birth for you and your baby. If you are dissatisfied with the care you receive from me, you may file a complaint with the Texas Midwifery Board at: Texas Midwifery Board Texas Department of State Health Services Mail Code 1982 P.O. Box 149347 Austin , Texas 78714-9347

E-mail: midwifery@dshs.state.tx.us Telephone: (512) 834-4523 Fax: (512) 834-6677 Website: http://www.dshs.state.tx.us/midwife/ State law requires a newborn child to be tested for certain heritable diseases and hypothyroidism. I have been approved by the state of Texas to collect the blood samples for these tests. This is the procedure known as the "Newborn Screen," which will occur at 3 days and 2 weeks postpartum. A midwife may not: (1) provide midwifery care in violation of midwifery board rule, except in an emergency that poses an immediate threat to the life of a woman or newborn; (2) administer a prescription drug to a client other than: (A) a drug administered under the supervision of a licensed physician in accordance with state law; (B) prophylaxis approved by the department to prevent ophthalmia neonatorum; or (C) oxygen administered in accordance with midwifery board rule; (3) use forceps or a surgical instrument for a procedure other than cutting the umbilical cord or providing emergency first aid during delivery; (4) remove placenta by invasive techniques; (5) use a mechanical device or medicine to advance or retard labor or delivery; or (6) make on a birth certificate a false statement or false record in violation of Section 195.003, Health and Safety Code. (7) except as provided by Section 203.403, use in connection with the midwife's name a title, abbreviation, or designation tending to imply that the midwife is a "registered" or "certified" midwife as opposed to one who is licensed under this chapter; (8) advertise or represent that the midwife is a physician or a graduate of a medical school unless the midwife is licensed to practice medicine by the Texas Medical Board; (9) use advertising or an identification statement that is false, misleading, or deceptive; or (10) except as authorized by rules adopted by the Texas Board of Nursing, use in combination with the term "midwife" the term "nurse" or another title, initial, or designation that implies that the midwife is licensed as a registered nurse or vocational nurse. A midwife certified by the North American Registry of Midwives who uses "certified" as part of the midwife's title in an identification statement or advertisement must include in the statement or advertisement a statement that the midwife is certified by the North American Registry of Midwives. A midwife may not use an identification statement or advertisement that would lead a reasonable person to believe that the midwife is certified by a governmental entity.

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Signature of Client_______________________________ Signature of Midwife ______________________

Date Signed _______________________ Date Signed ______________________

Client(s):
We have chosen to have a homebirth based on what we believe to be a thorough examination of the alternatives. We have discussed our prenatal care and birth options between ourselves, and with the midwife to the extent we think necessary. We have read the Informed Disclosure Statement above, and all our questions regarding Meg Glascoffs background and experience have been answered to our satisfaction. As a result we have asked Meg Glascoff, CPM, to provide care and assist us in our homebirth. In requesting the services of a Certified Professional Midwife, we freely exercise our right to seek the type of maternity services we feel are best for ourselves and our baby.

In choosing to have a homebirth, we are aware of possible risks involved and we knowingly accept any and all risks and responsibilities for this homebirth and the health of ourselves and our baby. We realize that no matter how carefully our risk status is assessed, emergencies or other unforeseen events can arise resulting in poor outcome. Obstetric emergencies and complications include, but are not limited to, labor prior to 37 weeks or after 42 weeks, abnormal vaginal bleeding, placenta previa or abruption, postpartum hemorrhage, retained or adherent placenta, pregnancy induced hypertension, prolonged rupture of membranes, fetal distress, prolapse of umbilical cord, stillbirth, respiratory distress, sepsis and shoulder dystocia. We understand that this list is incomplete, and agree to transfer mother and or infant to physician management and care if this is deemed necessary by our midwife. We are fully aware that in the event of a complication or emergency, there are fewer diagnostic and therapeutic measures available at a homebirth than there would be in a hospital setting, including some that may be life saving. We understand that this is the case and that some medical conditions may be more readily treated, with better outcome, in a hospital setting. We understand that our reception at a hospital in a transport situation may be less than pleasant.
We understand that if we refuse transport when it is recommended, the midwife and/or her assistants reserve the right to call an ambulance to stabilize mother and/or baby. We understand that we may terminate our midwifes services at any time. We understand that our midwife must practice within the parameters of Texas law, as well as common sense. We hereby release Meg Glascoff, her assistants, and consulting physicians for all liability arising from acts or omissions on their part while functioning according to their protocols. _________________________ Mother Date _________________________ Midwife Date ____________________________ Partner Date