Pregnancy and birth are a wonderful and natural process in life. Since having a baby is an experience that is only gone through a limited number of times in a person’s life, it should be as much of a memorable and pleasant experience as possible. With education and minimal interventions, my goal is to make a peaceful atmosphere for a safe, outside-the-hospital, family oriented birth.
As a certified midwife, I am dedicated to providing education prenatal care, labor and delivery assistance, and postpartum care. I am trained to find ordinarily identifiable and known complications, which make for a high risk pregnancy. Through informed choices, parents are taking control of the care they receive and creating the birthing experience that so many have come to know and love.
The following document is an informed consent for Sherry Bushnell, CPM. This is not meant to scare you with legal paperwork. If there is any part of this document that you have about questions or would like to discuss further, I would be more than happy to discuss those with you. My goal as a midwife is for you to have your baby in the atmosphere you want, with regard to safety and health for both mom and baby, without unnecessary interventions.
Nature and Scope of care:
v We start our care with an initial consultation: This is time for you to ask questions and get information to see if our services are what you are looking for and the care you desire for your growing family. Since a midwife can only continue care with normal, low risk childbirth, at this time we would rule out any obvious high-risk problems.
v A second visit will include obtaining recommended laboratory specimens, and an in-depth interview of your medical history.
v Prenatal checkups will be: Every month till 32 weeks, every 2 weeks till 36 weeks, every week from 36 weeks till delivery.
v If home birth is within 30 miles, at least one prenatal will be a home visit.
v Attendance at your labor and delivery.
v One or two qualified assistants will also be provided and will attend your birth.
v First postpartum visit at your home.
v Newborn genetic screening tests including PKU on the baby
v 2, 4 and 6 week postpartum visit at the birth center
v weight checks and informal visits on a continuing basis postpartum
v 24-hour availability by way of telephone or cell phone.
v We will bring to your home equipment and supplies necessary for a home birth. This includes herbs to control hemorrhage, and an electronic hand held doppler for monitoring the fetal heart rate during labor. We will give you a list of supplies you will need to gather also.
If any question or deviations from normal occur, a physician’s consultation will be sought. We work closely with Dr. Gregory Rice, and Dr. Anne Camber, in Libby, Montana. We consult with them if we have questions or an emergency arises. I am willing to work with the Dr. or OBGYN you wish, providing they are supportive of your choice to have an out-of-hospital birth.
Birth Center or Home Birth? Blessed Beginnings, in Bonner’s Ferry, is used for prenatals, childbirth education and occasional births. It is also used to help women in the community as a crisis pregnancy center. We also have the use of several birth centers, one of which is Family Birth Services, in Libby Montana, is a freestanding birth center 2 blocks from the hospital. There is no additional cost for the use of either facility.
Medical care for baby:
We would like to recommend that you find a health care provider for your baby. We will perform a basic physical exam on your newborn, but we are not specialists in the care of newborns. We recommend your baby be seen within 48 hours of birth for a more complete exam.
Legal responsibilities of the midwife:
You must be informed that our liability, in rendering care or assistance in good faith to a client of a direct entry midwife in an emergency situation, is limited to damages caused by gross negligence or by willful or wanton acts of omissions. It is required by both Idaho and Montana law that we file a birth certificate.
Responsibilities of client: Choosing an out-of-hospital birth is a big decision. We are counting on you to do your research. This means that you will collect information through reading books, the internet and talking with others to choose the best decision for our family. We will give information and inform you of these some of these choices as they occur. Issues such as immunizations, blood testing, eye ointment at birth, circumcision if needed, and vitamin K are just some of the areas you will need to make a choice for your baby. Taking responsibility for your health and your baby’s well-being is commendable. We ask that you will abstain from street drugs, over-use of caffeine, and other harmful behaviors. Good nutrition is a secret to having a good birth. We ask that you maintain a good-faith attempt in eating quality protein, fresh fruit and vegetables and whole grains to nourish both you and your baby.
Emergency and high-risk conditions: If you decide to use the birth center, Family Birth Services, in Libby, MT, Joyce Vogel, CPM will be your primary midwife for the actual birth in order to meet Montana regulations. You will need to be willing to read and sign her paperwork in addition to mine. The Montana state board of alternative health gives us a detailed list of what conditions we must consult or transfer care to a physician. We can show you this list by request. These laws are made for your protection, although the choice is always your decision.
The goal of the midwife is that every pregnancy results in a healthy mother and a healthy baby. As midwives we are taught when it is safer to transfer care because of high risks, or emergency situations. But there is no way a midwife or a doctor can guarantee a successful outcome. You or your baby may suffer serious problems during pregnancy, the birth itself or after birth due to natural processes and complications that are beyond the control of yourself, your midwife or physician.
In cases with complications I must consult or refer my clients to specialists. Joyce has back up physicians in Libby, MT, and I have a good relationship with the physicians here in Idaho with Sandpoint Women’s Health Care. They are all experienced and well qualified to handle most complications that may arise. If a complication should arise, we will discuss the care options with you. It is your right and responsibility to make the decisions about your care. I will give you as much information as possible and answer any questions to help you make informed choices. In the case of an emergency during labor we will try to make every effort to inform you of your choices in a timely manner. In an emergency situation we are equipped to begin treatment and to transport you and your baby to the nearest facility of your choice. If need be 911 will be called and you will be transported via ambulance or life flight.
If you feel you need to refuse recommendations by Sherry or Joyce, in the event that further testing or transport is deemed necessary for the safety of mother and/or baby, you assume all responsibility for outcomes resulting from such decisions. (Such conditions include, but are not limited to: submitting to normal prenatal care, testing for blood sugar levels, blood type, ultrasounds if warranted, testing for fetal distress, mother being exhausted or in shock etc). In the event that refusal of such recommendations are given, Joyce Vogel and Sherry Bushnell are given the right to refuse further care and will assist in transfer of care, if client so desires.
By signing this document, you acknowledge that there are risks to both mother and child in the childbirth process, that there can be no guarantees of a successful outcome, and that you understand these risks and voluntarily assume this risk.
We have read and understand this contact. We agree to the terms contained herein.
Client signature Date
Midwife’s signature _________________________________________________________Date ______________________________________________
Fees
There is a non-refundable $300 fee due at or before the 2nd visit. The remaining $2000 can be broken down into equal monthly payments to be paid at each prenatal visit. The fee must be paid in full by the 38-week appointment unless other arrangements have been made. This $2,300.00 fee is the cash discount price if paid before due date. Fees filed on insurance claims will be the normal customary fees for maternity care of $4,600.00.
Your fee includes: all routinely scheduled prenatal exams, childbirth education classes, labor monitoring, birth, immediate postpartum, monitoring for 5 or more hours, up to 4 postpartum and newborn visits, use of midwives standard equipment, an assistant at the birth, filing a birth certificate. Lab fees for standard tests are in addition to this price. Approximate prices for these tests are: prenatal profile $80, group B strep $20, and newborn screen $90. Glucose and hemoglobin tests are included. Ultrasound services, when recommended, are charged separately by those agencies. Care given by any other provider during your pregnancy is also in addition and your responsibility. Hospitalization and emergency services are also the separate responsibility of the client. There is no fee reduction for late prenatal or no prenatal care, as this could cause a high-risk situation.
If I attend any part of your labor, birth, or postpartum period, the fee will not be refunded, as there is no reduction in the actual care provided. This applies even if another provider is present and also bills for services which he or she renders. In most cases, more care is required in the event of a hospital transport for a complication since this requires the careful decision making skills for which midwives are trained and many more hours of time. If hospital transport is needed, I will continue to the hospital with you to help with your care, helping you to be able to make informed decisions. If I am your primary midwife, and you decide to have your baby at Family Birth Services’ birth center in Libby, MT, and agree to Joyce’s additional care, and the use of the birth center, there are no extra fees.
If the midwife misses the birth due to a very quick delivery or if the call asking for her assistance is made late, as a client, you agree to pay in full. If transfer is required or desired by either party before 36 weeks, as a midwife, I agree to prorate fees. After 36 weeks no refund is available. All trade for services is non-refundable.
It is understood that as a midwife, I have the right to withdraw my services if payment is not made or a special arrangement is not made.
I will also assist you in finding another provider.
We have read and understand this contact. We agree to the terms contained herein.
Client signature Date
Midwife signature Date
* In the case of a hospital transport the standard midwifery charge of $2300 plus the standard doctor fee of aprox. $700 charged by the doctor for delivery only, is still very comparable to the doctor’s complete normal prenatal/delivery fee of $2600. These prices are current prices in Libby as of 2005. Hospital charges in Libby generally cost $5000 in addition to doctor’s fees.
Sherry Bushnell, Certified Professional Midwife
Release
I have executed an agreement to obtain midwifery services from Sherry Bushnell, DEM. I have carefully read all of the provisions of the informed consent advisory and fully understand its content. I further understand that childbirth is a natural human process with inherent risks of complications. I have discussed my questions and concerns regarding the midwifery services offered to me with Sherry and/or her assistants. I agree to continue to discuss any concerns or perceived complications with Sherry. I am informed as to Sherry’s education, background, training and experience. I acknowledge and fully understand the services offered to me and the risks involved in accepting these services.
I hereby consent to services offered, fully acknowledging the risks inherent in childbirth.
Release:
As a participant in midwifery services, I on behalf of myself, my unborn child and each of our heirs, successors and assigns, hereby release and forever discharge Sherry Bushnell, or any of her assistants or affiliates, successors, assigns, agents or employees from any and all actions, causes of action, claims and demands and any and all other claims of every kind, nature and description whatsoever, both in law and equity, which may arises from or relate in any way to my participation in the midwifery service. I agree not to institute any action or suit against said parties, except if such actions arise out of willful or malicious conduct by Sherry Bushnell.
I understand that Sherry Bushnell is not making any warranty with respect to the outcome of my childbirth.
I understand the meaning and consequences of the informed consent and release, having discussed it with my attorney to the extent that I deemed appropriate. Furthermore, I hereby certify that I have not relied on any inducements, promises or representation of any person, which are not set forth in the informed consent and this release and it has been signed by me freely and voluntarily.
Mother’s signature______________________________________________Date_____________
Father’s Signature_____________________________________________Date______________
Patient HIPPA Form
Sherry Bushnell, CPM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by request.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
__________________________________________ _______________________
Patient signature Date
Extra fee if homebirth is over 30 miles from Libby $200
Name ___________________________________________ Date _________________________
Due Date ______________________________ Date of Birth _____________________________
Name of baby ________________________________________
These are the tests recommended by the Board of Montana. You may receive these tests here or from another provider. They are recommendations, and you may accept or refuse any test or procedure. By your initials, you are accepting or refusing for that test and /or procedure.
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Test |
How Test is performed |
When test is performed and why |
Permission Given |
Refusal of test or procedure. (May obtain from alternative provider.) |
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Urinalysis |
Urine sample |
Every visit: to monitor symptoms of pre-eclampsia and gestational diabetes. |
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Standard OB serological test—routine Approximate cost is $46.00 plus overnight shipping. ($17.00) |
Blood test drawn here at birth center |
ABO grouping and RH typing; antibody screen (includes ID and titer of all irregular antibodies detected); CBC with differential; HBsAg; rubella antibodies, IgG; syphilis serology (if positive, confirmation is performed by MHA-TP at an additional charge.)
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Pap smear prenatally |
Gentle swab of cervix |
Prenatally for early detection of cancer |
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Pap smear Postpartum |
Gentle swab of cervix |
6 weeks postpartum |
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Gonorrhea Chlamydia |
Urine test |
If you or your partner have had sexual intercourse with anyone else ever. Check for STD’s that can have harmful effects. |
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Glucose test for gestational diabetes |
Small finger poke done at birth center, after special meal or drink with a 50– gram load of sugar. |
Done at about 28 weeks to check for gestational diabetes, which can be serious and even fatal for the baby. If the result is high, will recommend further testing. |
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Routine ultrasound |
X-ray department at hospital |
20 –26 weeks to assess age and well being of baby. (If there is a specific need, will discuss separately.) |
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Alpha fetoprotein screen |
Blood test |
Done at 16—18 weeks, can detect some birth defects such as Down syndrome. |
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Vaginal Strep B |
Gentle swab of vagina and rectum at 37—38 weeks |
Detects active stage of vaginal strep B virus. |
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Eye ointment |
Ointment in newborn’s eyes within first 2 hours of birth |
Administered in baby’s eyes at birth, to kill possible gonorrhea or syphilis picked up in the birth canal. Generally no negative effects on baby. |
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Vitamin K |
Shot or drops |
Used to prevent intracranial hemorrhage. Ask for handout. |
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Newborn Screening |
Approximately 3rd day after birth we do a blood test from heel of baby’s foot. $90.70 for Montana and up. We can get a basic PKU, Galactocemia, and Hypothyriodism for around $67.00 through another source. A disclosure should be signed to notify Montana of your wishes to get it done elsewhere or not at all. |
Tests for several serious conditions such as PKU, congenital adrenal hyperplasia, galactosemia, and hypothyroidism. The multiple marker screening test (sometimes referred to as the triple or quadruple screen) is a blood test that can tell you whether your baby is at an increased risk for certain problems. A list of 28 different conditions and what they are can be accessed on the web at www.dphhs.mt.gov/PHSD/Lab/serology-index.shtml click on Newborn screening- clinical testing list of services. Or call 800-762-9891 |
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Bilirubin test |
Within 72 hours of birth, at hospital |
Tests for jaundice in baby |
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Newborn hearing test |
Within 1 month. (What they’d like you to do is bring baby in to the hospital on the way home.) Hearing test should be asked for. |
To check hearing and overall health of baby. |
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Permission to share basic birth information with newspaper, friends and acquaintances. |
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Do you mind if we share basic birth info (baby’s name, pictures, DOB, how you are doing…)? |
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I understand the purpose of having the following lab tests or procedure done. They have been explained to me and I am able to ask questions regarding my concerns. I understand the risks and complications of waiving these tests. I am agreeing to have only the tests performed that I have initialed next to. I understand the risk involved in refusing any of the tests and I voluntarily assume this risk.
Client signature_______________________________________ Date _____________
Sherry Bushnell, CPM
___________________________________________________ Date ______________
Sherry Bushnell, CPM - Client Registration
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Name First Middle Last
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Phone: work Home |
Today’s Date:
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Race |
Religion |
Marital Status
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Husband’s Occupation:
Wife’s Occupation: |
Client’s DOB
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State of birth: |
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Address: city state zip
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Father of baby:
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State of birth
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Father’s DOB
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E-mail address:
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Work phone:
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Previous forms of birth control: ______________________________ How long? ________________________
Gravida ____ Para _____ SAB’s _____TAB’s ____ Living ____Stillbirths _____ Blood type: _____________
When do you think you conceived? _____ LMP/ normal? _____ PMP _____ How long is your cycle? _______
Name of physician _______________________________ Pediatrition ______________________________
List all pregnancies and outcome:
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Name |
M/F |
DOB |
Gest. |
Weight |
Hrs. Labor |
Induce |
Meds |
Epiz? Location |
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6. |
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Problems in Current Pregnancy?
Allergy? _________________________________________________ Latex allergy? ____________
Immunizations: Rubella_________ Tetnus ________ Rh negative?_____ RhoGAM ___________
___ 1st trimester nausea ___ Spotting/ bledding ___ Headache Usual weight ________
___ 2nd/3rd trimester nausea ___ Premature labor ___ Dizziness Medications __________
___ Varicose veins ___ Anemia ___ Swelling
___ Bladder infections ___ Constipation ___ Gastritis
___ Kidney infections ___ Hemorrhoids ___ Heartburn PAP smear? __________
If yes, describe symptoms and treatment if applicable: _______________________________________________
Family History: Father of Baby: Your Mother’s History:
___Alcohol/drug abuse
___High blood pressure ___Sexually transmitted diseases No. of pregnancies _____________
___Cancer ___ Urethritis No. of live births _______________
___Diabetes ___ Herpes: Genital ____ Oral _____ Miscarriages ___________________
___Twins ___ Severe emotional problems Any complications ______________
___Severe Emotional problems ___ Alcohol/ drug abuse Your weight at birth ___________
Visit Check List
Sherry Bushnell, CPM
First or 2nd visit 30-26 Weeks
Go over contract Sleep on left side
Financial contract Edema and rings
Privacy contract How to prevent tears
Pregnancy history Extra phone numbers
Family history Braxton - Hicks
Nutrition / diet recall /vitamins Supply list
Records sent for Rh-negative handouts
Dr. Brewers web site Circumcision
Handouts 36 – 40 Weeks
My phone number list (weekly appointments)
Diet info Supplies together?
Red Raspberry tea handout Car Seat
Common annoyances Re-check HGB
Free hand out/ samples When to call us
Map to home / home visit
6 – 20 weeks Birth plan / tub/ water birth
Lab/ results LLL / Breast prep.
Test waiver form CPR / baby care
Nausea / vomiting Antibiotic eye ointment
Discuss desire for ultra sound Vitamin K
Cats Baby doctor
Work hazards Kick chart 39 weeks
Childbirth classes
Exercise
Quickening Postpartum
Vaginal bleeding Birth certificate
PKU
20-28 weeks Home certificate
Glucose tolerance test 28 weeks PAP smear
Rh antibody screen at 28 weeks Hgb 6 weeks
HGB recheck at 28 weeks Intercourse
Sonogram Fertility Awareness
Round ligament pain
Warning signs
Braxton-Hicks
Breast-feeding
Homebirth / birth center
Prenatal Record
Name:_______________________________________________________________________________
Due Date ___________________ LMP ___________________E-Mail _________________________
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Sono EDD |
Mom’s age |
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Home Phone: |
Work or Cell |
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Marital Status |
Father |
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Employment |
Religion |
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Birth Center Home Home Address: |
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Doctor |
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Blood Type |
Pre-pregnancy Weight |
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Date Delivered |
Name of Baby |
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Total Preg. |
Full Term |
Prematue |
Misca |
Ab |
Multiple |
Living |
Height |
Diet Pref. |
Quickening |
Group B |
Allergies |
Breastfeeding
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Date |
Weeks |
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G |
B/P |
Wt. |
Fund |
FHT |
Position |
Edema |
F. Move |
Hbl. |
Comments |
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Midwifery Notes:
Signature / Initals: _________________________________ ___________________________________________
__________________________________________________ ___________________________________________
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Labor and Delivery Record
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Name: Age: |
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Gravida: Para: LMP: EDD: |
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Last Hgb: Blood type Allergies |
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Date: Time: Time labor began: |
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B/P Pulse: Resp: Temp: Edema: |
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FHT: Position: Dilation: Effacement: Station: |
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U/Ctx. Time of onset: Frequency: Duration: Intensity: |
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Membranes: Intact / SROM/ Unsure Time: Fluid color Amount: |
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Bleeding: Amount: |
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Last Food eaten: Time: Vomiting: Last BM: |
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Emotional status: Other concerns: |
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Time FHT B/P/Te In/Out q Ctx. Dilation Eff. Station Comments ID |
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Time FHT B/P/Te In/Out q Ctx. Dilation Eff. Station Comments ID |
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Midwifery Notes:
Signature / Initals: _________________________________ ___________________________________________
__________________________________________________ ___________________________________________
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Date |
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Immediate Postpartum
Client’s name: ____________________________________________________ G__________ P _____________
Date of Birth: __________ Time of Birth: __________ am / pm Placenta: _____________ am / pm EBL at birth _________ ml.
Mec Stain: none light moderate thick
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Time |
B/P |
Pulse |
Condition of fundus |
EBL |
Urine |
Meds |
Comments |
Initials |
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