PREPARING FOR YOUR HOME BIRTH Please have the following things prepared for your 36-week visit BIRTH KIT Please order your birth kit from www.preciousarrows.com. You have the choice between 4 birth kits, all of which include free shipping. To find our kits, search: “Midwives Cooperative”.
NON-WATERBIRTH KITS: BASIC: http://www.preciousarrows.com/Midwives_Cooperative_Custom_Birth_Kit_p/80211-70.htm
DELUXE: http://www.preciousarrows.com/Midwives_Cooperative_Deluxe_Birth_Kit_p/80211-71.htm WATERBIRTH KITS:
BASIC: http://www.preciousarrows.com/Midwives_Cooperative_Basic_Birth_Kit_p/80211-72.htm
DELUXE: http://www.preciousarrows.com/Midwives_Cooperative_Deluxe_Birth_Kit_p/80211-73.htm
ADDITIONAL BIRTH SUPPLIES: Please gather and store in a closed bin. 2 sets of sheets (old ones, preferably) 1 box plastic garbage bags 6-8 bath towels Laundry detergent/bleach/oxi-clean (for blood Washcloths (stack of 8) removal) 1 roll of toilet paper Pot with tight-fitting lid (for hot compresses) Vinyl mattress cover or shower curtain liner Roll of paper towels Flashlight with battery 2 additional shower curtain liner(s) Heating pad or hot water bottle (optional) Bowl or Tupperware for placenta (6 qt.size) 1 quick read digital thermometer 1 bottle hydrogen peroxide 12-24 large disposable under pads (available 12-24 large maxi pads with wings in the incontinence section of grocery store or pharmacy)
FOR BABY FOR MOM 6 receiving blankets, soft cotton Gowns, t-shirts to labor in 2 baby hats Hair clips, ties, headbands 2 newborn outfits 2 pair of socks Diapers **IF YOU HAVE PETS, PUT ALL LINENS IN SEALED CONTAINER OR PLASTIC BAG**
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
FOOD FOR LABOR Cheese slices, apple slices, strawberries, banana, protein bars, boost type drink, smoothies, trail mix, peanut butter & crackers, yogurt, honey - other easy to eat foods that you like. Don’t forget snacks & drinks for your birth team! Plan for a long labor when considering food needs.
DRINKS FOR LABOR 2-4 large bottles of Gatorade, Recharge, or juice. Bottled water if you don’t use tap water. Plenty of ice!! Coffee or tea for your birth team.
FOOD AFTER BIRTH Large meal with protein, carbs & veggies. Warm tea, milk, whatever you might be craving!
COMFORT MEASURES Have things on-hand that you might enjoy in labor. Special music Candles and/or aromatherapy oils for diffuser Lotion for massage Lip-balm Rice sock (for warm packs) Cool pack Tennis balls (2-4 for massage), or other massage tools
BE PREPARED! Just in case we need to transfer to the hospital, please make the following preparations: Have your car seat installed and ready Make sure there is gas in your car at all times Make childcare arrangements (if needed) in case of transfer Emergency numbers on fridge Is your house number clearly visible from the street? Is your insurance card in your wallet?
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
EXTRA LIST FOR SUPPORT PERSON Camera/video camera/smartphone - check the batteries and/or charge! List of mom-approved contacts - Who should you call when she’s in labor? Who should you call when the baby is born?
PREPARING THE HOUSE Spend some time at home thinking about where you might be comfortable. Consider soft spots to lie on, whether it is comfortable to kneel on the floor, privacy, lighting, temperature and access to a bathroom. Try labor positions in different rooms. If you have mostly carpet, you may want some extra shower curtain liners so that you can labor without worrying about the rug.
If you plan to labor and/or birth in your bathtub, make sure there is plenty of cleanser available. Double-check laundry supplies (you won’t believe how much laundry a small baby can produce!).
PREPARING THE BED To make the birth bed, follow these steps before or during early labor: First put the vinyl cover on. Make bed with a set of sheets over the vinyl cover. Cover top sheet with shower curtain (or another vinyl cover). Make bed with a second set of sheets that are ok birthing on. After you have had your baby and are ready to get up to shower, we can strip the top layer off the bed and you will return to a magically clean, fresh set of sheets!
PREPARING YOUR BIRTH TEAM Include those who will be present at your birth in some appointments with your midwife. Communicate clearly to your team so they know what you will want them to do during your birth. Childcare arrangements - either at home or away - make sure there is a back-up plan (or two!).
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
BIRTH POOL RENTAL We are happy to offer families the option of waterbirth and/or the use of water in labor. Midwives Cooperative uses the La Bassine birthing pool for clients who choose to rent a pool.
La Bassine Birth Pool Features Cocoon like shape To provide an intimate space yet with plenty of room to move, without over taxing your hot water system. Holds around 120 gallons at 80% full. Deep Blue color To enhance the sense of privacy and induce deep relaxation. 3” inflated floor To give the extra comfort needed during active birth positions such as kneeling and squatting. Spacious Inner Space Internal Dimension : 125 cm x 95 cm (65" x 53") To give the perfect water depth that fully covers your belly without being too deep that you 65 cm depth (26”) feel insecure. 2 solid handles, exactly where you need them! Use to assist in position changes, or to grab on Internal handles to while you push, voted best feature by many women and midwives Carbon Neutral Made in Water Ltd has made a donation to the World Land Trust Carbon Balanced Fund to offset the carbon footprint incurred producing and shipping La Bassine. Ethically Manufactured All our manufacturers are independently audited to ensure safe and fair employment practice. Tens of thousands of pools sold worldwide, including in Europe, US, Canada, Australia and Proven in the field more – By far the best selling and most popular birthing pool.
The birth pool rental fee is $100. Please make checks payable to Midwives Cooperative or pay at midwivescooperative.com. The fee includes pool set-up (delivery, inflation with electric air pump, correct hoses and adaptors) and pool break down (drainage with pump, cleaning, deflation and removal).
PLEASE ENSURE THAT YOU HAVE PURCHASED THE WATERBIRTH KIT FOR YOUR BIRTH KIT. It will come
with a personal liner that fits just right in our pool rental.
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
ONE-HOUR GESTATIONAL DIABETES SCREENING INSTRUCTIONS This test is routinely performed as part of your 26-28 week labs
1. This is not a fasting test, but prior to eating the glucose load avoid sugary foods, sugary drinks and high carb meals. This can compromise the test results.
2. At ______, eat all 18 jelly beans provided by the midwives. This will equal 50 grams of glucose. Not all jelly bean brands have the same sugar content, so use the ones provided to you!
3. Consume the jelly beans within 5 minutes and do not eat or drink anything (except water) afterward.
4. Midwives will see you at ______on ______for your prenatal visit.
5. Midwives will draw your blood at ______.
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
FETAL KICK COUNTS Begin assessing fetal kick counts in your third trimester (after 28 weeks)
Counting your Baby's Movements A simple way to check your baby's well-being is to pay attention to how much your baby is moving. Most babies move at least 10 times within two hours.
Count your baby's movements once a day, at the same time each day • Lie on your left side and focus on your baby's movements: rolls, kicks or flutters. • Use the chart below to record the number of minutes it takes to feel your baby move 10 times. • You may stop counting after your baby has moved 10 times. Your baby should move 10 times in 2 hours. Do this once a day at approximately the same time each day. (Babies' activity levels are usually higher in the evening after dinner.)
DAILY KICK COUNTS Record the number of minutes it takes to feel your baby move 10 times Week of pregnancy 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Remember: If your baby does not move at least 10 times in 2 hours or if there is a sudden decrease in movement, call your midwife.
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
NewboRN Home Visiting Program Participant Consent and Release Form
PARTICIPANT INFORMATION NAME DATE OF BIRTH LAST 4 DIGITS OF SSN
ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER (INCLUDE AREA CODE) E-MAIL
RELEASE OF INFORMATION
I understand that this program is funded by the Alachua County Board of County Commission as recommended by the Children’s Services Advisory Board. I also understand that certain information including name, unique ID number, zip code, race, and age for all those served may be shared with the funding organization and other partners. I understand that this data will only be used for program monitoring, funding, coordination and planning purposes. I understand that home visiting services provided by the NewboRN Home Visiting Program of the Healthy Start of North Central Florida Coalition may involve communication with other agencies that work together to provide services to me and my child(ren). I hereby give permission to the NewboRN Home Visiting Program to disclose and to obtain information from the agencies below as indicated by my initials. This includes, but is not limited to records of my care, treatment, and health such as intake forms, consults, home visiting sessions, immunizations, applications and financial information. The purpose of this release is to ensure my family and I receive the best possible services and support. This may include services related to health and safety, financial assistance, child development, and parent education. Information will be released based upon the need to know and HIPAA privacy regulations. I hereby release the agencies listed below that have been INITIALED, their employees and representatives, from all liability relating to or arising out of this release of information.
Please INITIAL: I also authorize specific health information to be disclosed which includes any of my psychiatric/psychological and alcohol and drug use and treatment. ____ YES ____ NO
Please INITIAL all agencies below that are included in this consent:
_____ UF Health Shands HomeCare _____ NurseCore _____ UF Center for Health Policy
_____ Coordinated Intake & Referral _____ Medical Care Providers______
_____ Other______
Version- 4-12-2018
The purpose of this consent is to allow for unrestricted communication concerning services being provided. I do NOT wish the following information to be disclosed: ______
______
RELEASE OF INFORMATION FOR REPORTING As part of my participation in the NewboRN Home Visiting Program, I understand that information will be collected about my family and me for the purpose of program reporting. The funder, Healthy Start of North Central Florida, Inc.; the evaluator, the University of Florida; and the software providers, GoBeyond, will have access to confidential information about my family and me including Social Security numbers.
I understand that all information about my family and me will be kept confidential. Nothing will ever be said or written about my family as individuals and our names will never be used, unless it is required by law or if I agree in writing.
CONSENT TO RECEIVE SERVICES I have read and understand the above. I hereby authorize the NewboRN Home Visiting Program to render appropriate services to me and my child (ren). I understand such care will be provided by an appropriate level of staff and/or health care personnel. I recognize and agree that I have the right to refuse or terminate services at any time. By signing this consent form, I agree to allow the information described in this consent to be collected and kept by the NewboRN Home Visiting Program.
SIGNATURE OF PARTICIPANT OR OTHER REPRESENTATIVE’S SIGNATURE (IF DATE APPLICABLE)
PRINTED NAME
WITNESS SIGNATURE DATE
PRINTED NAME
This program is funded by the Alachua County Board of County Commissioners based on recommendations from the Children’s Services Advisory Board.
Version- 4-12-2018
GROUP B STREP: WHAT YOU NEED TO KNOW
What is group B strep? Group Beta Strep (streptococcus) is a type of bacteria that can cause serious illness and death in newborns. Until recent prevention efforts, hundreds of babies died from group B strep every year. This type of bacteria can also cause illness in adults, especially the elderly, but it is most common in newborns.
Why do I need to get tested for group B strep during each pregnancy? Group B strep bacteria can be passed from a mom who is a carrier for the bacteria (tests positive) to her baby during labor. Since the bacteria can come and go in your body, you need to be tested for group B strep every time you are pregnant, whether you tested negative or positive during the last pregnancy. Toward the end of pregnancy (35-37 weeks), the midwife will swab your vagina and rectum. This is sent to a lab, where they test for group B strep bacteria. The bacteria take a few days to grow, and the results are sent to your midwife.
What happens to babies born with the group B strep bacteria? Group B strep is the most common cause of sepsis (blood infection) and meningitis (infection of the fluid and lining around the brain) in newborns. Most newborn disease happens within the first week of life, called “early onset” disease. In the year 2001, there were 1,700 early-onset cases in the U.S.
How can group B strep disease in babies be prevented? Most early onset group B strep disease in newborns can be prevented by giving antibiotics through the vein during labor to women who tested positive during their pregnancy. Because the bacteria can grow quickly, giving antibiotics before labor has started does not prevent the problem. Any woman who has a positive test for group B strep during this pregnancy should get antibiotics. Also, any pregnant woman who has had a baby in the past with group B strep disease, or who now has a bladder (urinary tract) infection caused by group B strep should get antibiotics during labor.
What if I’m allergic to some antibiotics? Women who are allergic to some antibiotics, such as penicillin, can still get other types of antibiotics. If you think you are allergic to penicillin, talk with your midwife.
How does someone get group B strep? Anyone can be a “carrier” for group B strep. The bacteria are found in the gastrointestinal tract (guts) and may move into the vagina and/or rectum. It is not a sexually transmitted disease (STD). About 1in 4 women carry these bacteria. Most women would never have symptoms or know that they had these bacteria without a test during pregnancy.
If I know that I’m a group B strep carrier, why can’t I just take some antibiotics now? For women who are group B strep carriers, antibiotics before labor are not a good way to get rid of group B strep. Because they naturally live in the gastrointestinal tract (guts), the bacteria often come back after antibiotic treatment. Antibiotics during labor are effective at protecting your baby because they greatly reduce the amount of bacteria the baby is exposed to during labor. Even if you had IV antibiotics for your last baby, you may not need them for this pregnancy if you are not a carrier now. That’s why it’s important to get tested during every pregnancy.
What do I need to do during pregnancy or labor if I’m group B strep positive? Talk with your midwife and create a labor plan that includes getting antibiotics for group B strep prevention in your newborn. When your water breaks, or when you go into labor, make sure you call your midwife immediately so that you can increase your chances of getting antibiotics at least four hours before your baby is born. Talk with your pediatrician about your GBS status, as he or she may want to see the baby within the first 24 hours.
For more information, go to the Centers for Disease Control and Prevention (CDC) website at: www.cdc.gov/groupbstrep
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
INFORMED CONSENT FOR GBS SCREENING & TREATMENT
1. All clients will be offered a screening culture between 35-37 weeks gestation for Group B Strep. Exceptions are below. Clients who fall under A and B are considered positive by the CDC and should be treated accordingly. A. Any client who has a Urine C&S which is positive for Beta strep during pregnancy. B. Any client with history of a previous child with positive B Strep infection. 2. If the client’s culture is negative, no further treatment is necessary. 3. If the client has preterm labor, premature rupture of the membranes, Group B strep bacteriuria, or develops a fever in labor, the midwife will consult with or transfer to the nurse practitioner or obstetrician for prescription medication or further care. 4. If a client’s culture is positive, they will be recommended IV antibiotic prophylaxis in labor for B Strep. During counseling the client will be advised: A. The risk of her child becoming infected with B Strep is 1-2 in 1,000. B. If a child becomes infected with B Strep, the risk of death is 5-20%. C. Intravenous antibiotics are an effective prevention for most cases of newborn GBS infection. D. The greatest chance of prevention is achieved if the antibiotics are given within 4 hours of the birth. E. These antibiotics can cause allergic reactions in the mother which can be serious or rarely fatal. F. The client may choose to birth at the hospital, whether they elect to receive antibiotics or not, so that the baby may be observed for 24-48 hours. G. If the client chooses to birth out of hospital: (1) the consulting pediatrician will be notified by the client of the positive GBS status before the planned home birth; and (2) the mother/caretaker will complete the newborn assessment record for the first three days of life, and report to the midwife immediately any deviations from the normal given on the assessment record. The pediatrician may suggest further testing or observation at his/her discretion, including outpatient laboratory blood testing (i.e. CBC, blood cultures, etc.), and/or observation of the newborn either at home, or at the hospital for 24-48 hours after the birth, depending upon the circumstances. 5. The client is asked to read this information and designate her choice of options below. 6. Current CDC recommended Prophylaxis for B Strep: (Subject to modification by consulting obstetrician/pediatrician) A. Ampicillin 2grams, then 2.5 million units IV or 1 gram Q 4 hrs. until birth. B. Penicillin allergic - Erythromycin 500 mgs. IV Q 6 hrs. until birth or Clindamycin, 900 mgs. IV Q 8 hrs. until birth
I HAVE READ THE ABOVE INFORMTATION AND DESIGNATE MY SCREENING AND TREATMENT OPTIONS AS FOLLOWS:
SCREENING I understand I will be screened with a culture prior to 36 weeks, and if positive, I understand I will be encouraged to take the preventative IV antibiotic treatment in labor.
Patient Name & Signature: ______Date: ______
Midwife Signature: ______Date: ______
TREATMENT I have been advised that my GBS culture is positive, and I elect the following treatment options: No antibiotic treatment during my labor and birth out of hospital. Reason: ______ IV antibiotic treatment during my labor and birth at out of hospital. Birth at hospital. Patient Name & Signature: ______Date: ______
Midwife Signature: ______Date: ______
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
GROUP B STREP: PREVENTATIVE APPROACH
Group B strep (GBS) bacteria testing occurs at your 36-37 week visit or a positive result may have been reported during a routine urine screen in early pregnancy. If you are GBS colonized, we recommend treatment according to guidelines from the Centers for Disease Control. However, there are holistic measures you can take during pregnancy to reduce the chance that you will test positive. The following measures may help to minimize your risk of any infections and maximize the ability of your immune system. You may choose to incorporate any of the following suggestions as they work for you:
Get extra sleep before midnight. Slow down your schedule. Follow a routine you may use when trying not to get sick: rest, boost immune system with vitamin C and D supplementation, minimize stress. Maintain good vaginal hygiene habits: wipe front to back, rinse off after sex, and wear breathable (cotton), clean underwear Treat vaginal infections right away. If you have a yeast infection in pregnancy, little cracks in your tissue give B-strep bacteria more places to grow. Vaginal infections should be treated promptly. Ask your midwives about using suppositories made from healing herbs to promote healthy tissues in your vagina. Echinacea: a cup of echinacea tea or take 2 capsules of echinacea every day Vitamin C: good sources of Vit C include red peppers, citrus, and kiwi fruit. If you are taking a vitamin C supplement take no more than 2000 mg/day Capsicum (cayenne pepper) is higher in vitamin C than any other known substance and chases bacteria and viruses from the body. Garlic: known to have antimicrobial and antifungal properties and lowers blood pressure and cholesterol to boot. If you wish to supplement, take two 580 mg capsules twice a day Grapefruit seed extract: take 15 drops twice a day Astragalus: tincture, 3 droppers twice a day, or special order the dried root and include in soups and teas. It is a general booster for the immune system. Probiotics: Supplement with the helpful bacteria acidophilus and bifidus, twice daily take 4 billion cells per dose.
Source: Lemay, Gloria. Group B Strep: What you need to know. 2011. http://wisewomanwayofbirth.com/group-b-strep-what-you-need-to-know/
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
INFORMED CONSENT FOR VITAMIN K INJECTION
Why is vitamin K given to newborns? There is a rare disease called Vitamin K deficiency bleeding, which occurs in approximately 1/10,000 babies. In about half of babies who suffer this bleeding problem after the first week of life, many will die or sustain significant brain-damage due to the disease, because of bleeding into the brain. It occurs almost exclusively in breast-fed babies and is almost completely preventable by giving extra vitamin K after birth.
Which babies are most at risk of this bleeding problem? The early type of bleeding is a particular risk for babies whose mothers were on certain drugs during pregnancy, such as anticonvulsants (for epilepsy). The late bleeding disease is more common in babies who are born premature, who have had a complicated delivery (such as a breech delivery, forceps or vacuum), or those who have liver disease or difficulty absorbing feeds. Many babies who go on to have more serious bleeding problems suffer smaller bleeds from the skin, nose or mouth in the weeks before this.
Why not just give vitamin K to those at high risk of bleeding? Unfortunately, in about 1/3 of cases the vitamin K deficiency bleed occurs without prior warning or risk factor. It has been estimated that if vitamin K were only given to high-risk babies, among a sample of 800,000 or so annual births, there might be: • 60-80 babies who suffer a bleed • 15-20 babies suffering a bleed into the brain • 4-6 babies who die from the bleed into the brain • 10-20 babies who may be brain damaged because of the bleeding
What is the controversy about vitamin K? Since the 1960's vitamin K has been used widely in the US, throughout Europe and the UK, being given as a single injection just after birth. This is cheap and effective, with no recorded treatment failures, even in babies with liver disease, who are at most risk. Concerns about the safety of this arose in the early 1990's when 2 papers were published in the medical literature, suggesting an association between vitamin K injection and childhood leukemia (a blood cancer). The papers looked at children with leukemia and checked how many of them had received vitamin K injection compared to children without leukemia. They found an increased risk of leukemia by a factor of about 1.8. Following this very unexpected finding, lots of other comparisons were made throughout the world to see if this was indeed a true increase in risk or just a chance happening in this group. Studies from the UK, USA, Germany and Sweden found no evidence to support these findings. A Danish study followed all children born in Denmark over a 40-year period from 1945 and compared the leukemia rates in those receiving no vitamin K, vitamin K by mouth and vitamin K injection and found no difference. More recently a Scottish study looked at over 400 children aged up to 14 years with cancers and found no association between vitamin K injection and any cancer. Two more studies were published this year containing a total of 4000 cases of childhood cancers, demonstrating no association with vitamin K usage.
What do the 'experts' say? • A joint UK Medicines Control Agency, Committee on the Safety of Medicines and Department of Health expert group has concluded that overall, the available data do not support an increased risk of cancer, including leukemia, caused by vitamin K. • The American Academy of Pediatrics concludes vitamin K injection prevents a life-threatening disease of the newborn and the risks of cancer are unproven and unlikely' and recommends a single injection for all neonates.
So what should I do? The State of Florida requires Vitamin K injections. The standard of care in our community is to provide a single dose injection of Vitamin K for the newborn after birth. However, like all medical treatments, the decision to have Vitamin K treatment is ultimately in your hands. The evidence on the risk of leukemia associated with vitamin K injection does not suggest an increased risk, but it is not possible to completely, 100% exclude this at present. The risk of the vitamin K deficient bleeding disease is well known and almost 100% preventable by vitamin K injection.
Text adapted from materials by Author D.E. Tucker, MRCOG
Informed Consent: I have read the above information and have made an informed decision. I elect to have my newborn treated / not treated (circle one) with Vitamin K. If I decline treatment, my reason is: ______
Parent Name & Signature: ______Date ______
Midwife Signature: ______Date ______2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
INFORMED CONSENT FOR NEWBORN ANTIBIOTIC EYE PROPHYLAXIS
Administration of erythromycin (antibiotic ointment) aims to prevent infection, or pink eye, from bacteria that may have been transmitted from the mother’s vagina into the baby’s eyes during the birth process. Florida Law requires the administration of antibiotic eye ointment to the eyes of the newborn within two hours of birth.
The primary infection this treatment is designed to prevent is Gonorrhea. Of newborns born to mothers with untreated gonorrhea, between 1 in 2 to 1 in 3 risk developing gonorrheal infection of the eye, which carries with it a high risk of blindness. Left untreated, gonorrheal infection of the eye can begin to cause vision loss in as little as 24 hours.
Prophylactic eye ointment may also prevent other infections including Chlamydia, Streptococcus, and Staphylococcus. Bacteria other than gonorrhea and chlamydia are thought to cause 30-50% of newborn eye infections. Antibiotic ointment may or may not be effective in treating these infections and is not 100% effective at preventing gonorrheal eye infection. Risks may include eye irritation and blurred vision.
Source: https://evidencebasedbirth.com/is-erythromycin-eye-ointment-always-necessary-for-newborns/
I have read the above information and have made an informed decision. I elect to have my newborn treated / not treated (circle one) with erythromycin eye ointment. If I decline treatment, my reason is:
______
Parent Name: ______
Parent Signature: ______Date ______
Midwife Signature: ______Date ______
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
Newborn Screening Information and Waiver
The state of Florida screens all newborns for various conditions soon after birth. While most babies arrive into the world healthy, there are a few newborns who have a rare health problem. The intent of the Newborn Screening Program is to screen, identify, diagnose, and manage newborns at risk for selected disorders that, without detection and treatment, can lead to permanent developmental impairments, delayed physical growth, severe illness, and death through early detection and intervention. With appropriate timely treatment, newborns identified through the Newborn Screening Program will have the opportunity to grow and reach their potential. There are 3 components to the Newborn Screening Program: metabolic, hearing and pulse-oximetry.
METABOLIC SCREENING
The Newborn Metabolic Screening (formerly known as the PKU test) is a blood test that identifies rare metabolic, endocrine, enzymatic, and other genetic disorders in the newborn. The Florida screening looks for 32 disorders recommended by the United States Human Services Recommended Uniform Screening Panel and an additional 22 secondary disorders, unless a parent objects in writing. After 24 hours of protein feeding, five drops of blood are taken from the heel of the baby and sent to the state lab for analysis. I have read the above information and have made an informed decision. ⃞ I elect to have Newborn Metabolic Screening to be performed by my midwife at the 24-48 hour home visit. ⃞ I elect to have Newborn Metabolic Screening to be performed by my pediatrician at a newborn pediatric visit. ⃞ I decline the Newborn Metabolic Screening for the following reason(s) detailed in the written statement of objection:
______
HEARING SCREENING
The most critical time for a child to learn language is in the first 3 years of life, when the brain is developing and maturing. Children begin learning speech and language in the first 6 months of life and research shows that children with hearing loss who get help early develop better language skills than those who don’t. In 2000, the Florida Legislature authorized a statewide program for early hearing impairment screening for all newborns. It is recommended that this screen be performed within the first 30 days after birth. This hearing screen must be performed by a licensed audiologist, physician or specially trained person under their supervision. The Midwives Cooperative is not able to perform this screening, but your pediatrician may offer it. If not, they can provide you with a referral to a specialist. Parents or legal guardians may waive this screening.
I have read the above information and have made an informed decision. ⃞ I elect to have Newborn Hearing Screening to be performed or arranged by my pediatrician. ⃞ I decline the Newborn Hearing Screening for the following reason(s) detailed in the written statement of objection:
______
PULSE OXIMETRY SCREENING
Pulse oximetry, or pulse ox, is a painless, non-invasive test that measures how much oxygen is in the blood. Infants with heart problems may have low blood oxygen levels, and therefore, the pulse ox test can help identify babies that may have Critical Congenital Heart Disease (CCHD). The test is done using a machine called a pulse oximeter, which is a sensor placed on the baby’s skin. The pulse ox test only takes a couple of minutes and is performed after the baby is 24 hours old. I have read the above information and have made an informed decision. ⃞ I elect to have Pulse Oximetry Screening to be performed by my midwife at the 24-48 hour home visit. ⃞ I elect to have Pulse Oximetry Screening to be performed by my pediatrician at a newborn pediatric visit. ⃞ I decline the Pulse Oximetry Screening for the following reason(s) detailed in the written statement of objection:
______
Newborn Screening Program contact information
For further details on newborn screening, please reach out to the Florida Department of Health using the information below:
Phone: 850-245-4201 Email: [email protected] Website: http://www.floridahealth.gov/programs-and-services/childrens-health/newborn-screening/
INFORMED CHOICE STATEMENT: I have read and understand the importance of the newborn metabolic screen and understand why screening is recommended. I have been provided resources for further research and education regarding the newborn metabolic screening. I have read and understand this information and have had an opportunity to ask questions. I will in no way hold Midwives Cooperative liable for my decision. I am fully aware of the risks of refusing the newborn metabolic screen and have freely chosen to take the following action:
Patient’s Name & Signature: ______Date: ______
Midwife’s Signature: ______Date: ______
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com
PEDIATRICIAN LIST
Type Provider Name Phone Number Address City Pediatrics North Florida Pediatrics 386-755-4432 1117 NW Hwy 41, Suite B Jasper
Pediatrics North Florida Pediatrics 386-758-0003 1859 SW Newland Way Lake City
Pediatrics Magnolia Pediatrics 386-719-6500 1140 SW Bascom Norris Dr. Lake City
Pediatrics Children's Medical Center 386-755-1546 789 W Duval St. Lake City
Pediatrics High Springs Pediatrics & Primary Care 386-454-1156 19228 NW US Highway 441 High Springs
Pediatrics Children’s Medical Center 386-462-1911 14861 NW US HWY 441 Alachua
Pediatrics Dr. Luis Scaccabarrozzi, MD 352-332-4400 6440 W. Newberry Rd. Gainesville
Pediatrics UF Health Pediatrics - Tower Square 352-733-1770 7046 Archer Rd. Gainesville
Pediatrics UF Health Pediatrics – CMS Center 352-334-0206 1699 SW 16th Ave., Bldg A Gainesville
Family Practice UF Health Family Medicine – Eastside 352-265-7015 410 NE Waldo Rd. Gainesville
Pediatrics Worthington Pediatrics 352-371-3604 5528 NW 43rd St. Gainesville
Pediatrics Benton Pediatrics 352-376-4542 5612 NW 43rd St. Gainesville
Pediatrics Dr. Rosario Fortunato, MD 352-375-0001 2131 NW 40th Terr., Suite A Gainesville
Pediatrics Dr. Ana Moros-Hanley, M.D 352-333-0085 2005 SW 75th St. Gainesville
Family Practice Palms Medical Group 352-376-8211 1014 Northwest 57 St. Gainesville
Pediatrics Dr. Elizabeth Benitez, MD 352-332-2345 215 NW 138th Terr., Suite 100 Jonesville
Public Health Azalea Health 352-481-2700 22066 NE 71st Pl. Hawthorne
Pediatrics PedIM Healthcare 352-527-6888 1990 N. Prospect Ave. Lecanto
Pediatrics Dr. Chris Okonkwo, MD 352-671-1800 1301 SE 25th Loop Ocala
Pediatrics Dr. Humeraa Qamar, MD 352-369-8690 1750 SE 28th Loop Ocala
Pediatrics Marion Pediatrics 352-369-1001 3105 SW 13th St Ocala
Pediatrics Premier Pediatrics 352-671-6741 7960 SW 60th Ave Ocala
Peds/Family Absolute Health 352-854-5530 7350 SW 60th Ave., Suite 2 Ocala
Suggested questions to ask: • Do you accept my insurance? • Are you currently accepting new patients? • Do you require I follow the recommended vaccination schedule? • How soon after my birth do you want to see the baby? • Do you provide lactation support? • Do I have to come into the office for an appointment before my baby is born?
2602 NW 6th St., Suite B, Gainesville, FL 32609 ∙ 352-377-3879 ∙ www.midwivescooperative.com