Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 502 - BOARD OF COMPLEMENTARY HEALTH CARE PROVIDERS › Chapter 6-C - STANDARDS FOR VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC) › Informed Consent for Out-of-Hospital Vaginal Birth After Cesarean

Current through 2024-29, July 17, 2024
Client's Name Midwife's Name
Parents planning a Vaginal Birth after Cesarean (VBAC) with a
				  Certified Professional Midwife or Certified Midwife will complete the following
				  informed consent; in the presence of their Certified Professional Midwife or
				  Certified Midwife. It is the responsibility of the client to voice all
				  questions and concerns regarding their out of hospital VBAC choice; and it is
				  the responsibility of their midwife to address their questions and provide up
				  to date data and research on the risks of out of hospital VBAC choice.
Client Initials
[] I have read my midwife's informed consent for out of
				  hospital VBAC, discussed the topic in depth, and have had all of my questions
				  and concerns addressed.
[] I am aware of the risks associated with planned Vaginal
				  Birth after Cesarean, including the risk of uterine rupture. I understand that
				  if my uterus were to rupture in labor this could result in serious damage to
				  myself and my baby, and there is an increased risk that my baby could
				  die.
[] I understand that being a greater distance from emergency
				  services could increase the risk to myself and my baby. I have discussed the
				  distance from hospital of my intended place of birth with my midwife.
[] I understand that I have the option to attempt a VBAC at a
				  hospital, or to plan a repeat Cesarean at a hospital.
[] I agree that if my Certified Professional Midwife or
				  Certified Midwife recommends a transfer I will comply with their
				  recommendation.
Licensed Certified Professional Midwives
				  and Certified Midwives in Maine are required by law to confirm the following
				  information regarding your pregnancy; please
				  confirm:
[] I have had only one previous Cesarean and the scar is in
				  the lower part of my uterus.
[] My single previous Cesarean occurred 18 months or more
				  before the due date of my current pregnancy.
[] I will give permission for the release of the operative
				  records of my previous Cesarean birth to my midwife.
[] I agree to having at least one prenatal ultrasound in the
				  second or third trimester of this pregnancy to determine the location of my
				  placenta.
[] I agree to having lab work done in this pregnancy that
				  determines my blood group and type.
[] I understand that my midwife will not induce or augment my
				  labor by any botanical or pharmacological means.
[] I understand that my midwife will monitor my baby's heart
				  tones in labor often, at least every 15 minutes in active labor and every 5
				  minutes during pushing.
[] I understand that my midwife will be monitoring my vital
				  signs and be assessing for signs of uterine rupture during my labor, as well
				  as, monitoring for normal labor progression.
[] I agree to there being an additional provider assisting my
				  midwife at my labor and birth.
[] I understand that I must agree with all of the above
				  provisions in order to have an out of hospital planned VBAC with a Certified
				  Professional Midwife or Certified Midwife.
Affirmation
I understand that these measures are required to improve the
				  safety of my care. Given the increased risks associated with planning an out of
				  hospital VBAC, I agree that if my midwife recommends a transfer of care or
				  emergency transport in labor I will promptly comply with this recommendation.
				  Having received adequate information and resources, and having had my questions
				  addressed, I express my understanding of the risks and my desire to initiate
				  care with -
Certified Professional Midwife's or Certified
				  Midwife's Name (print legibly)
________________________________________________________________________________________________________________________
Certified Professional Midwife's or Certified
				  Midwife's Signature
________________________________________________________________________________________________________________________
On (date)
________________________________
Client's Name (print legibly)
________________________________________________
Client's Signature
________________________________
On (date)
__________________________
Disclosure Statement:
This form is prescribed by the Maine Board of Health Care Providers and
				  adopted under Board Rule Chapter 6-C on August 18, 2021. Any tampering,
				  modifications, or alteration of the content of this form is prohibited.
				  Exception: A licensee may insert this form, in whole, onto their business
				  letterhead if desired.