Welcome to Rosemary Birthing Home Care

Welcome to Rosemary Birthing Home Care.

Your midwife is Harmony Miller, LM- Florida Licensed Midwives practicing under Florida’s Midwifery Practice Act – FS Chapter 467.

The midwife provides prenatal, labor, birth and postpartum care to well women expecting to have a normal birth. We are experts at helping you labor and birth naturally. Women who birth at Rosemary Birthing Home do so without analgesics or anesthetics.

Throughout your care we will use the Florida Licensed Midwife risk assessment to evaluate your ongoing health and appropriateness for birth center care. This will be specifically reviewed with you initially, at 28 weeks (7 months) and at 36 weeks gestation (8 months) or if you develop a risk factor.

Referral is available should you desire or require ultrasound and/or consultation with an Advanced Registered Nurse Practitioner or Obstetrician. If you develop a risk factor that requires consultation we will attempt to collaborate with a consulting physician so that you may remain under our care.

In the event you develop a risk that requires a higher level of care than we provide at the birth center, we will refer you to a local hospital based care giver for completion of your care.

Should a risk develop quickly during your pregnancy, and you need testing or treatment at the hospital, we would refer you to the on-call physician at the closest hospital to your home.

If a complication develops during labor or birth we will consult with a physician. If transfer becomes necessary, you may need to go to Sarasota Memorial Hospital, or the hospital closest to you if birthing at home, where the on call physician will manage your care. The midwife will support you throughout this process.

Birthing outside the hospital is safe for women having normal healthy pregnancies and expected to have a normal birth. The midwives have carefully crafted a schedule of prenatal visits which allow time for discussion and suggestions to support you in creating a healthy happy pregnancy, birth and postpartum.

You will need to take good care of yourself during your pregnancy by eating a healthy diet and maintaining a healthy lifestyle. You will need to prepare yourself for birth at the center with attendance at our childbirth education series, a birth plan and a support team. Your postpartum recovery will require an extra degree of planning since you will return home within six hours of your birth. The midwives will advise you regarding putting these plans in place.

We are excited to work with women and families who want to take on a full measure of responsibility for their health and the health of their children. We believe that pregnancy and birth are a sacred passage through which a family is created. It is our joy to share our knowledge with you throughout your journey and upon your arrival in parenthood. *We DO carry malpractice insurance in the amount of: $100,000/$300,000

Harmony A. Miller Consent to Deliver in a Birth Center

1. I have already voluntarily chosen to deliver my child in Rosemary Birthing Home bit\rth center. I have already made this decision after being informed that in the course of childbearing, which is a normal human function, medical problems may be unpredictable and suddenly arise which may present a risk to myself and the unborn child. I understand that the birth center is not a hospital and has no facilities to do emergency cesarean sections, has no intensive care units for newborns or adults, and does not provide general anesthesia or epidurals. I am aware that the practice of medicine, midwifery, and nursing are not exact sciences, and I acknowledge that no guarantees or assurances have been made to me concerning the results of the treatments, examinations, and procedures to be performed. I hereby release the birth center and the staff from all liability from complications which may occur during the course of my labor and delivery of my child as a result of my choice to use the birth center.

2. I am also aware of the benefits of natural childbirth relating to avoidance of potential injury resulting from invasive procedures, anesthesia, or surgical intervention.

3. I am aware that the clinical staff who will provide prenatal services and attend me during labor and delivery are: Harmony A. Miller, LM CPM and Alina Vogelhut, LM CPM and are duly licensed to practice in the state of Florida.

4. Should any medical problems arise during my labor, I am aware of the medical necessity for and hereby consent to my immediate transfer to the hospital for further care. If this should be necessary, I understand that the rules and regulations of the hospital must be adhered to.

5. Should any medical problems related to the well-being of my newborn infant arise after delivery, I am aware of the necessity for and hereby consent to the immediate transfer of the infant to: Sarasota Memorial Hospital or other closest emergency OB facility for further care.

6. I understand that all hospital and medical expenses incurred as a result of complications shall be my obligation and are not included in the financial arrangements with the birth center.

______Signature of patient

______Date ______Witness

AHCA Form 3130-3003 March 94 (Rev. 12/28/2007) HOLD HARMLESS AND RELEASE OF LIABILITY

I agree as follows: WHEREAS RELEASER (S), being over the age of 18, or being an emancipated minor, and in consideration of my decision, to and for myself, heirs, executors, administrators successors and assigns, hereby, fully release and forever discharge Venetian Isle Medical Consultants, Wayne P. DiGiacomo, Coalition for Childbirth Choices, its employees, affiliates, successors, assigns, and their respective heirs, executors, administrators, successors, affiliates, successors, assigns (hereafter all collectively referred to as “RELEASEES” of and from any actions, causes, or right of action, suites, damages, judgments, executions, claims, demands whatsoever, known and unknown, from the beginning of the world to the end of time, arising from my decision.

This release contains the entire agreement between the parties hereto, shall not be altered except in writing signed by both parties, and shall be considered a contractual agreement, and not a mere recital. RELEASER FURTHER STATES THAT HE OR SHE HAS CAREFULLY READ THIS ENTIRE AGREEMENT, SIGNED OF HIS OR HER OWN FREE WILL, AND IN SO DOING, ACKNOWLEDGES AND AGREES TO ABIDE BY THE CONDITIONS REFERENCED.

______Patient Date

______Licensed Midwife Date CONFIDENTIAL CLIENT INFORMATION

Legal Name: FIRST MI LAST MAIDEN Street Address: PO Box #

Mailing Address (if different): Email Adress:

City: State: Zip Code:

Home Phone # Work Phone # Education: Race

Marital Status: S M D W Sep Age: Birth Date: Birth Place

Social Security # Driver’s License #

Occupation: Employer’s Name Employer’s Address Phone # 

Spouse’s or Significant Other’s Name:

Birth Date: Birth Place Social Security # Education:

Occupation: Employer:

Employer’s Address: Phone #



How did you learn of Rosemary Birthing Home?

Referring Individiual:

Address:

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IN CASE OF EMERGENCY CONTACT:

Phone # Address:

Relationship:



Health Insurance Company Policy Holder

Policy # Group #

PAYMENT IS DUE AT TIME OF SERVICE UNLESS CREDIT ARRANGEMENTS ARE MADE IN ADVANCE. Insurance will not be billed for GYN services. You will be provided an itemized statement to assist you in filing your claim. I hereby authorize payment directly to the The Rosemary Birthing Home for the medical care and pregnancy benefits otherwise payable to me. I understand that I am financially responsible to the Birthing Center for charges not covered by this authorization. I authorize the release of any medical information to any insurance company necessary to review this claim.

DATE: Signed: Witness:

Office Use Only EDC 32 Week Date

Rosemary Birthing Home Intake Sheet

Name: ______Date: ______

Address: ______City: ______Zip: ______

Phone: ______Cell: ______

Email address:______

Age: ______Date of Birth : ______

LMP:______Gravida/Para ______EDB: ______

______

Social Security number: ______

Spouse Social Security number: ______Husband/partner: ______

Client’s occupation: ______

 Insurance, Name of company: ______HMO/ PPO/PHO Address of company: ______Phone: ______

Group/Plan # ______Policy ID # ______Subscriber’s Name: ______& Date of birth ______

 Medicaid, number: ______

 Self-pay, details of plan ______FINANCIAL CONTRACT

Financial responsibility is part of preparation for parenthood as well as assuring the continuation of care at Rosemary Birthing Home.

The fee for Prenatal, Birth, and Postpartum Care at Rosemary Birthing Home is $5000.00. A $500 fee is due at the first visit with a midwife. Payment is due in full by 32 weeks of pregnancy. Failure to meet financial responsibility as outlined in the terms of this contract will result in the discharge of the patient from midwifery care. This fee includes:  Prenatal Midwife Availability - 24-hour on-call midwifery care.  Prenatal Care - Personalized, education-intensive prenatal care on a regular schedule appropriate to gestational age.  Child Birth Education Program - This program is taught by our childbirth educator.  Birth Care and Continuous Labor Support - Personalized midwifery care for birth at home or the birthing home. This includes labor checks, continuous labor support and birth care, complete newborn exam, the presence of a trained birth assistant in addition to the midwife and non-medical midwife support in the event of transfer to a hospital.  Midwifery Equipment, Supplies and Medications for Birth – Emergency equipment and all herbs and homeopathy used in labor and birth.  After Birth Care – At least one postpartum home visit, on call assistance including lactation counseling and two postpartum office visits.

This fee does not include:  Birth Kit - The patient is required to purchase a birth kit for either home or birthing home birth. A detailed list of supplies and birth kit order information is given at the 28 week visit.  Labs or Ultrasounds - There is a basic set of required tests that will either be billed to Medicaid, insurance or the patient. Additional testing may be required if a medical complication arises.  Physician Referrals, Consults, or Management of Care - Medical care by a physician, if required, will be an additional expense that will be billed by the physician providing the care.  Hospital or Ambulance Transport Costs - Hospitalization at any point during care, if required, will be an additional expense that will be billed by the institution providing the care.  Rhogam shots – Patient will be billed for Rhogam injections given at 28 weeks and after birth if the mother’s blood type is Rh negative.  Antibiotics used in labor and delivery and the Newborn Metabolic and Hearing Screening. Rosemary Birthing Home offers several options with regard to financial arrangements. Rosemary Birthing Home accepts Medicaid, HMO coverage, 100% client payable contracts and will negotiate with all major insurance companies.

A. Medicaid

Rosemary Birthing Home is a Medicaid Provider. Medicaid covers all maternity services. Medicaid does not cover the newborn metabolic and hearing screenings or blood bank charges if the patient is RH negative. The patient will be responsible for those charges. Patient must report to Rosemary Birthing Home, and in a timely fashion, any changes to Medicaid eligibility status. Patient must notify Rosemary Birthing Home if Medicaid assigns them to Medipass or a Medicaid HMO. The patient will provide Rosemary Birthing Home with the baby’s Medicaid number within two weeks of birth. Charges for services provided to the newborn will be billed to the patient for failure to provide the information.

B. HMO

Health Maintenance Organization contracts which provide coverage, benefit or services for maternity care shall provide, as an option to the subscriber, the services of nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed pursuant to ss. 383.30-383.35. (from F.S. 641.31) All applicable co-payments required by my HMO policy will be collected by Rosemary Birthing Home. If there are any problems with reimbursement from the HMO, the patient will provide full assistance and documentation to Rosemary Birthing Home to secure payment.

C. Patient Payable

Rosemary Birthing Home offers a discount for those patients paying the full fee without insurance or other funding assistance. A 10% administrative discount will be given if the fee is paid in full by the second prenatal visit.

D. Insurance

Most insurance companies will reimburse professional services obtained at Rosemary Birthing Home. Rosemary Birthing Home uses a medical billing service and it is the patient’s responsibility to assist them and Rosemary Birthing Home in verifying with the insurance company as to whether or not care will be covered. Rosemary Birthing Home will accept third party payments directly from insurance companies. Patient is responsible for payments of the deductible and any co-payment, according to the provisions of their policy. Computation of the deductible and co-payment due to Rosemary Birthing Home will be based on the reimbursement policy of the individual insurance company on a case-by-case basis. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. Patient is responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Our medical billing service will assist patients in getting their insurance company to process claims based upon our full fee and not a reduced one.

If for any reason, payment from the insurance company is not received in a timely fashion by Rosemary Birthing Home, it will be the patient’s responsibility to promptly satisfy any unpaid portion of the fee. Any refund of excess payment will be made after full settlement of the account.

The patient is financially responsible for the care and treatment provided by the midwife. They agree to make payments according to insurance/self-pay schedule. Failure to pay for services rendered will result in interest at the rate of 1.5% per month (18% per annum). Any outstanding fees not paid in full after six months postpartum will be sent to collections. Patient will then be held responsible for the fees billed by Rosemary Birthing Home as well as the charges incurred from the collection agency. There is a $20.00 service charge on all returned checks. If there is more than one returned check, the remaining payments will be made in cash or by money order. If any difficulty with payment is anticipated, other arrangements can be made. We accept MasterCard, Visa, Discover, American Express and debit cards for our patient’s convenience.

All fees will be paid by the thirty-second week of pregnancy. There is no reduction in fee if prenatal care is begun late, as such a policy may be misconstrued to encourage delayed enrollment in care. Full payment is due to Rosemary Birthing Home if the midwife is not present for the birth because of failure of the patient to notify the midwife in a timely manner or at all, or in the event of an unusually fast birth, or other circumstances beyond the control of the midwife. Because midwifery care is based on holistic patient care, not just delivering the baby, the patient will be charged the full midwifery care fee even if the baby is not delivered by the midwife or if delivery is not at home or at the birthing home. If there is a transfer to the hospital during labor or immediately postpartum, the midwife will go to the hospital if circumstances allow.

Doula care is available through Rosemary Birthing Home. The patient is financially responsible for these services if doula care is chosen or needed during birth. The fee is $500.00 and is not covered by Medicaid or insurance.

Families that discontinue care with Rosemary Birthing Home will be responsible for charges incurred prior to transferring out of care. Refunds will be given if patient elects to transfer out of care before the onset of labor, or it becomes medically necessary to do so. These will be based on the care rendered by the midwife according to the following schedule:

Initial Consultation Free of Charge Initial Prenatal Visit $400.00 Prenatal Visit $150.00 each Birth Fee, Including Assistant $1950.00 Newborn Exam $250.00 Postpartum Care $500.00 Childbirth Education $400.00

Listed below are items that are not included in the regular fee. Antibiotics are used on an individual basis. The following items may not be covered by Medicaid or insurance.

IV Antibiotic $ 25.00 per dose/ Price includes administration supplies Rhogam $150.00 Metabolic Screening $ 50.00 Hearing Screening $ 50.00

O Positive and RH Negative Moms: Cord and maternal blood will be collected and sent to the blood bank for studies. The patient’s insurance company will be billed for lab work and Rhogam. Medicaid does not cover lab work but does pay for Rhogam. Any unpaid balance will be billed to the patient.

Beta Strep Positive Moms: Patients will need IV antibiotics in labor and baby may need additional tests. Please speak to the baby’s pediatrician regarding need for testing the baby and the fees.

In signing below, I make an agreement for pregnancy and birthing care with Rosemary Birthing Home. In addition, I authorize Rosemary Birthing Home to bill third party payers. I authorize direct payment of medical benefits to Rosemary Birthing Home for all services rendered. I agree and accept the terms of this contract and any exceptions are appended below:

______

______Mother of Baby Date

______Father of Baby Date

______Rosemary Birthing Home Representative Date Rosemary Birthing Home

Rosemary Birthing Home endeavors to provide you with the privacy your medical records require.

Please check below the ways that you approve for sharing information with you and other care providers and insurance.

◊ You may email communications to me. My email address is: ______◊ You may leave messages on my answer machine.

◊ You may leave a message with my spouse/partner regarding my care.

◊ I prefer to be spoken to on the phone, no messages please.

◊ You may send my information to a lab for insurance billing and processing – via fax or written by courier.

◊ You may fax or email information for insurance billing purposes to our billing agent Express Claims or Medicaid.

◊ Other ______

______Client Signature Date

NAME PRESENT PREGNANCY Last menstrual period (1st day) __ Normal?  Yes  No Suspected date of conception MEDICAL HISTORY - Please indicate if you have ever had any of these; when: Pregnancy test (date) Planned pregnancy  Yes  No Severe headaches  Bowel problems/ colitis Feelings about pregnancy  Eye/vision problems  Blood in stool Father’s/Partner’s feelings  Ear/hearing problems  Gall bladder problems Most recent birth control used  Dental problems  Liver problems Contraception used in past: what, when, any problems?  Thyroid problems  Hepatitis

 Rheumatic fever  Diabetes  Blood clotting problems  Hypoglycemia  Anemia  Bladder Infection  Hemorrhage  Kidney Infection Please indicate if you’ve had any of the following problems  High Blood Pressure  Urinary Surgery during this pregnancy:  Varicose Veins  Urethral Dilation  Nausea  Urinary complaints  Hemorrhoids  Aching Joints  Vomiting  Abdominal/pelvic pain  Tuberculosis  Pelvic/back Injuries  Fever  Vaginal bleeding/spotting  Asthma  Seizures  Infections  Vaginal discharge  Skin Disorders  Cancer  Headache  Bleeding gums  Stomach problems  Hospitalizations  Dizziness  Varicose veins  Ulcers  Surgeries  Indigestion  Hemorrhoids  Chicken Pox  Other  Leg cramps  Depression  Rash  Loneliness Do you have any allergies?  Yes  No  Backache  Family/relationship problems Please list and describe reaction: __ _  Swelling  Work problems ______ Constipation  Other _  Diarrhea

GYNECOLOGIC HISTORY Please indicate if you have used, experienced, or been Age at first period Cycle length (days) exposed to any of the following during this pregnancy: Duration Regular?  Yes  No  Tobacco  Herbs When was your last Pap smear?  Alcohol  Fumes/sprays Have you ever had an abnormal Pap? ___ (dates)  Caffeine  X-rays Please describe  Marijuana  Ultrasound  Cocaine  Measles/Viruses Please indicate if you have ever had any of the following; when:  Street drugs  Travel  Yeast  HPV  Other meds  Vaccinations  Trichomonas  Cervical surgery  Non-pres. drugs  Cats  Group B Strep  Cervical polyp  Vitamins  Other  Bacterial Vaginosis  Ovarian cyst  Chlamydia  Fibroids Please use this space to add any other information  Gonorrhea  Endometriosis regarding any of the above:  Syphilis  Abnormal bleeding  PID/Pelvic infection  Uterine surgery  Genital sores  Breast lump(s)  Herpes:  Genital  Breast surgery Please explain your type of dietary habits / diet  Oral  Infertility  Condyloma (warts)  Other

Are there any particular ethnic, cultural or religious preferences I choose to have my baby at Home/Rosemary Birthing for your care during pregnancy and birth that you would like to Home because discuss?

Are you Happy? Explain All of the information provided is true to the best of my knowledge

(sign) (date) Rosemary Birthing Home 800 Central Avenue Sarasota Florida 34236 Health History tel:(941)330-9966 fax (941)330-9921

Name SSN Phone (home) (work)

Ethnicity Spiritual Orientation Yrs Educ Occupation Date of Birth Marital Status Years Together

Address/Zip Code Inside City Place of Birth Limits?

Husband/Partner Race Yrs Educ Date of Birth Place of Birth

Address (if different from above) Occupation/Type of Business Phone (work)

Religion Any Children from Previous Relationships? Father’s SSN

Referred By

Please answer the following questions which will help determine if there are potential problems which should be discussed further. This information is completely confidential.

FAMILY HISTORY - Indicate if anyone in your FATHER OF BABY (FOB)- Indicate if the baby’s YOUR MOTHER’S HISTORY - Please immediate family has ever had any of these, who; when. father has ever had any of these and when. answer the following regarding your mother.

 Heart/Lung/TB  Sexually transmitted diseases  No. of pregnancies  Cancer  Herpes:  Genital  Oral  No. of births  Diabetes  Severe emotional problems  Miscarriages  Twins  Alcohol/drug abuse  Any complications  Severe emotional problems  Tobacco use  Your weight at birth  Bleeding Disorders  Other  Did she take DES with you?  Other

PREVIOUS PREGNANCY OUTCOMES Please complete this table regarding your own pregnancies (from earliest to most recent) Date # Weeks Birth / Miscarriage / Termination Comments/Problems

Yes No Will you be over 35 years old when the baby is due? Yes No Do you or the FOB have any family members with mental retardation, birth defects or genetic/inherited conditions? Yes No Do you have a history of infertility, miscarriages, stillbirths or serious pregnancy complications? Yes No Are you or the FOB from any of these ethnic/racial groups? (circle) Jewish Black/African Asian Mediterranean Yes No Have you or the FOB ever had hepatitis or jaundice? Yes No Have you ever used any drug intravenously (IV) or had a blood transfusion? Yes No Have you ever had a sexual partner who used any drug IV, had a blood transfusion, or had bisexual relations? Yes No Do you think you are at increased risk for AIDS/HIV? Yes No Have you ever experienced dramatic fluctuations in your weight? Do you believe you are overweight? Yes No Have you ever had anorexia, bulimia or other eating problems? Yes No Is there anything about the development of your sexuality that you would like to discuss? Yes No Have you ever been in an abusive relationship, including now, or been abused (physically or emotionally intimidated, beaten, injured, or made to take part in sexual activities against your will)? Yes No Have you ever had severe emotional problems? Yes No Have you ever been on any medication for psychological problems? Yes No Has anyone ever told you, or do you think, you have ever used alcohol or drugs excessively?

Getting To Know You

1. What do you feel are the benefits to you of receiving your prenatal care and giving birth at Rosemary Birthing Home or at home? Why did you decide on a birth center/home birth?

2. How did you come to know about Rosemary Birthing Home and our services?

3. What has been the reaction of friends and family about your decision to have your baby in an out-of-hospital setting?

4. How long have you and the father of the baby been together?

5. How has the pregnancy affected the relationship between the two of you?

6. …..the relationship between the two of you and other family members?

7. Have either of you noticed a change in the other? If so, how or what changes?

8. Describe your lifestyle, hobbies as a family and spiritual beliefs.

9. How will a baby fit into your current lifestyle and future plans?

10. Describe your past birthing experience (s):

11. What impressions did your mother give you/is giving you about pregnancy and birth?

12. In what areas of pregnancy, birth and parenting do you feel you may need special support or education?

Risk Assessment Form

Client name: Age: G/P: Risk score: Risk Factors with a Score of Three (3) Points Each Birth site > 30 minutes from emergency care Hgb < 9.3 g/dL or Hct < 28% Chronic hypertension Sickle cell anemia Heart disease, cardiac diastolic murmur, systolic ≥ 5 term pregnancies murmur grade III or higher, or Incompetent cervix with medical treatment cardiomegaly PAP smear suggestive of dysplasia Congenital heart defects 3 or more consecutive spontaneous abortions Pulmonary embolus 1 septic abortion Epilepsy or seizures in the last 2 years PPH unrelated to management Required use of anticonvulsant drugs Previous placental abruption Diabetes Mellitus Previous Rh sensitization Renal disease Stillbirth > 20 WGA or neonatal loss not due Severe or undiagnosed headaches to cord accident Bleeding disorder or hemolytic disease Birth weight < 2500 g (5½ lbs) or 2 or more pre- Cancer of the breast in the last 5 years term labors with no subsequent fullterm AGA baby Thyroid disease requiring medication other than Previous infant with major congenital anomalies, replacement therapy genetic or metabolic disorder Current drug or alcohol addiction or use of Nullipara > 22 WGA with no prenatal care addicting drugs Multipara > 28 WGA with no prenatal care Current mental health problems requiring Clinically diagnosed pathological uterine myoma, medication abdominal or adenxal masses Asthma in the last 5 years, current, chronic, or Prior uterine surgery requiring medication Poly- or oligohydramnios in current pregnancy Smokes > 10 cigarettes per day Positive serological test for syphilis Active tuberculosis HIV positive Risk Factors with a Score of Two (2) Points Each Pre-pregnancy weight outside the range for height 5’ 4” 103-175 lbs 5’ 9” 121-202 lbs 4’ 8” 83-143 lbs 5’ 92-157 lbs 5’ 5” 106-180 lbs 5’ 10” 124-208 lbs 4’ 9” 85-146 lbs 5’ 1” 95-161 lbs 5’ 6” 110-185 lbs 5’ 11” 128-212 lbs 4’ 10” 86-150 lbs 5’ 2” 97-166 lbs 5’ 7” 113-190 lbs 6’ 131-217 lbs 4’ 11” 89-153 lbs 5’ 3” 100-170 lbs 5’ 8” 117-196 lbs 6’ 1” 135-222 lbs History of oligohydramnios Severe PIH during last pregnancy History of polyhydramnios Previous C/section with subsequent low risk VBAC Risk Factors with a Score of One (1) Point Each Heart disease or congenital heart defects Prior psychotic episode with psychiatric evaluation & assessed by a cardiologist as no risk medication, not currently on medication History of pyelonephritis Hgb < 10.3 g/dL or Hct < 31% History of gestational diabetes Asthma not medicated, no current problems History of thyroid surgery Smokes ≤ 10 cigarettes per day Stable on thyroid replacement therapy EDD < 12 months from previous birth Chronic bronchitis 2 consecutive SAB or > 3 SAB (total) Previous placenta previa Previous baby < 2500 gms (5½ lbs) or ≥ 2 preterm labors Previous infant > 4000 gms (> 8 lbs 14 ozs) with ≥1 subsequent normal pregnancy & term AGA infant Age < 16 or > 40 years old I have participated in this risk screening and given accurate information to determine my eligibility for midwifery services: ______Client’s Signature Date

Reference FAC 64B24-7.004(1)(2): “The Licensed Midwife shall risk screen potential patients using criteria in this section. If the risk score reaches 3 points the midwife shall consult with a physician who has hospital obstetrical privileges and if there is a joint determination that the patient can be expected to have a normal pregnancy,labor and delivery the midwife may provide services to the patient.” MDC/MDW/Hdr/Clinical Info/MDW2211/Risk Assessment Form.doc Genetic Testing Informed Consent

There a variety of tests available to pregnant women to help evaluate for genetic problems with the fetus. None give a 100% guarantee of a normal baby. These tests include:

First Trimester Screen Between 11th and 13th week gestation (10.3-13.6) Usually performed at 12wga Maternal blood draw and ultrasound Specific chromosomal abnormalities, inc. Downs Syndrome, Trisomy-21 and 18 and some cardiac disorders. Does not detect neural tube disorders. Is considered a screening not diagnostic. Further testing may be needed if results indicate. 5% false positive rate.

Maternal Serum Alpha-fetal protein testing or Quad Screen 15- 18 weeks gestation 16 weeks gestation (15 – 18) Maternal blood draw Screen for 60 –70% Down’s Syndrome, 85-90% Neural Tube Defects, Omphaloceles, etc. Is considered a screening not diagnostic May require further testing such as amniocentesis False positives (30%) & false negatives

Chorionic Villus Sampling CVS 9 -11 weeks gestation Insertion of collection tool via cervix or abdomen Some risks involved – miscarriage, damage to embryo, hemorrhage, infection, etc. Screens for: toxoplasmosis in the fetus, Tay Sachs, urea cycle defects, congenital adrenal hypoplasia, hemoglobinopathies, cystic fibrosis, hemophilia A & B, etc. (does not test AFP) False positives possible but considered diagnostic Also provides predelivery paternity testing

Amniocentesis 16-18 weeks gestation Insertion of needle through the abdomen to collect amniotic fluid Detects many disorders but is not a guarantee of a normal baby (3%) Some risks involved – damage to baby, placenta or cord, infection, hemorrhage, miscarriage (< 0.5%), RDS,etc. False positives possible but considered diagnostic Also provides predelivery paternity testing

I have discussed these tests with my midwife and feel confident that I understand the implications of testing or not testing.

 I request ______tests.

 I decline testing.

______Signature of Client Date