Form

Crystal Fink CPM, LM

1917 Franklin Rd. SW Roanoke, VA 24014 Phone: (540) 676-7288 Fax: (757) 774-5078

Email: breathoflifemidwife@yahoo.com www.breathoflifemidwifery.webs.com
Disclosures by Licensed Midwives for High-Risk Pregnancy Conditions Virginia Board of Medicine
Client Name *

First Name Last Name
Client Estimated Due Date *

- Month - Day Year
Preamble:
The Midwives Model of Care® recognizes the client/patient as the primary decision maker in all aspects of her care and respects her autonomy. This is supported within a model of well‐informed, shared decision‐making in order to achieve optimal clinical outcomes. Disclosure of risks is an integral part of the informed consent process, as outlined by NARM (the North American Registry of Midwives).
“If a midwife supports a client’s choices that are outside of her Plan of Care, she must be prepared to give evidence of informed consent. The midwife must also be able to document the process that led to the decision and show that the client was fully informed of the potential risks and benefits of proceeding with the new care plan. It is the responsibility of the midwife to provide evidence-based information, clinical expertise, and when appropriate, consultation or referral to other providers to aid the client in the decision making process.” – NARM
Licensed midwives are trained experts in the management of low-risk pregnancy and birth outside of the hospital. Certain conditions may present increased risk to mother and/or baby. The risks listed below apply to birth in any setting, and are not all-inclusive. The condition/risk factor listed may require medications and treatments outside of the scope of practice of Virginia Licensed Midwives and, thus may necessitate consultation with a physician, additional testing, and careful consideration for the appropriateness of birth in an out-of-hospital setting. Some conditions in pregnancy should be optimally managed and supported by a multidisciplinary team that may include midwives, obstetricians, perinatologists, family physicians, psychologists, social workers, and spiritual advisors
Because the uterine scar for most caesarian sections is low on the uterus, women who undergo TOLAC (trial of labor after cesarean), are able to give birth vaginally 60–80% of the time. But if problems arise during TOLAC, the baby may need to be born by emergency cesarean delivery. Because uterine rupture can be sudden and unexpected labor outside of a hospital can delay delivery and increase the risk of injury and death for both mother and baby in an emergency. Some surgery for fibroids can result in a similar risk for uterine rupture. An unknown type of prior uterine scar is a contraindication for TOLAC so review of prior surgical records is essential part of the evaluation.

RISKS

Maternal risks

• Maternal hemorrhage

• Infection

• Thromboembolism

• Placenta accreta

• Death

• Emergency hysterectomy

Fetal risks

• Hypoxic Ischemic Encephalopathy

• Stillbirth

• Perinatal death

• Neonatal death

• Respiratory morbidity

• Transient tachypnea

• Hyperbillirubinemia

The probability that a woman attempting TOLAC will achieve VBAC depends on her individual combination of factors.

Selected Clinical Factors Associated with Trial of Labor after Previous Cesarean Delivery Success
Increased Probability of Success

• Prior vaginal birth

• Spontaneous labor

Decreased Probability of Success

• Recurrent indication for initial cesarean delivery (labor dystocia)

• Increased maternal age

• Non-white ethnicity

• Gestational age greater than 40 weeks

• Maternal obesity

• Preeclampsia

• Short interpregnancy interval

• Increased neonatal birth weight

(8) http://www.webmd.com/baby/tc/vaginal-birth-after-cesarean-vbac-risks-of-vbac-and-cesarean-deliveries
Client Choice and Signature

As required by the regulations for her practice as a Virginia Licensed Midwife, my midwife has discussed this information with me and has provided me with options for consultation and referral to a physician for the risk factors she has indicated apply to me. I have decided to:
Consult with a physician regarding my risk factors. Decline Consultation with a physician regarding my risk factors.
Client *
Partner/Witness

First Name Last Name
Partner/Witness
Midwife: Crystal Fink CPM, LM
A Work Group comprised of members of the Board of Medicine and the Advisory Board on Midwifery has developed this information to assist licensed midwives in
satisfying the requirements of Code Section 54.1-2957.9(iv), which requires midwives to disclose to their patients options for consultation and referral to a physician
and evidence-based information on health risks associated with the birth of a child outside of a hospital. This information does not constitute medical advice,
diagnosis, opinion or treatment. Individuals should consult a qualified health care provider for advice regarding a medical condition.
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Disclosures by Licensed Midwives for High-Risk Pregnancy Conditions Virginia Board of Medicine

Client Choice and Signature