INFORMED CONSENT FOR DOMICILIARY CARE
(HOME OR FREE-STANDING BIRTH CENTER)
LABOR AND / OR SUBSEQUENT SPONTANEOUS BIRTH
I (we) have voluntarily chosen to labor at home until such a time as we either want or need to transfer to the hospital or the labor spontaneously culminates in the out-of-hospital birth of our baby.
I (we) have made this decision after being informed that in the natural course of childbearing, which is a normal human function, medical problems can unpredictably and suddenly arise which may present a hazard to myself and my unborn/newborn child. I understand that equipment for dealing with these potential problems is most readily available in the labor and delivery complex of an acute-care hospital where the intrapartal events would be under the supervision of a medical doctor.
I (we) understand that risk is always present in life, including childbearing, regardless of the intrapartal location, due to unforeseeable complications and/or human error.
Certain risks are greater in a medical setting (i.e. unwanted interventions and/or interference with physiological nature of the birth process that cause complications and lead to unnecessary surgery, hospital-acquired infections, drug and anesthetic reactions, medication errors, other iatrogenic & nosocomial complications, etc) and certain risks are more prevalent in a domiciliary setting (i.e. no immediate access to blood transfusions, delay in being able to respond to immediate surgical needs (such as but not limited to emergencies as acute fetal distress, premature seperation of the placenta, maternal hemorrhage, etc).
I (we) hereby state that I (we) are aware of the nature and the magnitude of risks assumed by choosing domiciliary care and that we are willing to assume primary responsibility for the consequences of this decision.
I (we) have thoroughly read and clearly understand all of the above.
Client: ________________________________________ Date: _____________ Partner: ________________________________________ Date: _____________ Midwife: ________________________________________ Date: _____________