C.M.R. 02, 502, ch. 6-C, Informed Consent for Out-of-Hospital Vaginal Birth After Cesarean
Client's Name Midwife's Name
Parents planning a Vaginal Birth after Cesarean (VBAC) with a Certified Professional Midwife or Certified Midwife will complete the following informed consent; in the presence of their Certified Professional Midwife or Certified Midwife. It is the responsibility of the client to voice all questions and concerns regarding their out of hospital VBAC choice; and it is the responsibility of their midwife to address their questions and provide up to date data and research on the risks of out of hospital VBAC choice.
Client Initials
[] I have read my midwife's informed consent for out of hospital VBAC, discussed the topic in depth, and have had all of my questions and concerns addressed.
[] I am aware of the risks associated with planned Vaginal Birth after Cesarean, including the risk of uterine rupture. I understand that if my uterus were to rupture in labor this could result in serious damage to myself and my baby, and there is an increased risk that my baby could die.
[] I understand that being a greater distance from emergency services could increase the risk to myself and my baby. I have discussed the distance from hospital of my intended place of birth with my midwife.
[] I understand that I have the option to attempt a VBAC at a hospital, or to plan a repeat Cesarean at a hospital.
[] I agree that if my Certified Professional Midwife or Certified Midwife recommends a transfer I will comply with their recommendation.
Licensed Certified Professional Midwives and Certified Midwives in Maine are required by law to confirm the following information regarding your pregnancy; please confirm:
[] I have had only one previous Cesarean and the scar is in the lower part of my uterus.
[] My single previous Cesarean occurred 18 months or more before the due date of my current pregnancy.
[] I will give permission for the release of the operative records of my previous Cesarean birth to my midwife.
[] I agree to having at least one prenatal ultrasound in the second or third trimester of this pregnancy to determine the location of my placenta.
[] I agree to having lab work done in this pregnancy that determines my blood group and type.
[] I understand that my midwife will not induce or augment my labor by any botanical or pharmacological means.
[] I understand that my midwife will monitor my baby's heart tones in labor often, at least every 15 minutes in active labor and every 5 minutes during pushing.
[] I understand that my midwife will be monitoring my vital signs and be assessing for signs of uterine rupture during my labor, as well as, monitoring for normal labor progression.
[] I agree to there being an additional provider assisting my midwife at my labor and birth.
[] I understand that I must agree with all of the above provisions in order to have an out of hospital planned VBAC with a Certified Professional Midwife or Certified Midwife.
Affirmation
I understand that these measures are required to improve the safety of my care. Given the increased risks associated with planning an out of hospital VBAC, I agree that if my midwife recommends a transfer of care or emergency transport in labor I will promptly comply with this recommendation. Having received adequate information and resources, and having had my questions addressed, I express my understanding of the risks and my desire to initiate care with -
Certified Professional Midwife's or Certified Midwife's Name (print legibly)
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Certified Professional Midwife's or Certified Midwife's Signature
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On (date) ________________________________
Client's Name (print legibly) ________________________________________________
Client's Signature ________________________________
On (date) __________________________
Disclosure Statement:This form is prescribed by the Maine Board of Health Care Providers and adopted under Board Rule Chapter 6-C on August 18, 2021. Any tampering, modifications, or alteration of the content of this form is prohibited. Exception: A licensee may insert this form, in whole, onto their business letterhead if desired.
C.M.R. 02, 502, ch. 6-C, Informed Consent for Out-of-Hospital Vaginal Birth After Cesarean