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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Informed Consent and Waiver of Medical Referral For Vaginal Breech Birth

The Medical standard of care for breech-presenting babies is to do a cesarean section in most cases. First time mothers are considered to have an "unproven" pelvis which means that it is not certain that a baby can fit through it. Even women who have had a baby are encouraged or made to have a c-section due to the increased risks to the baby during delivery. Since the standard has become c-section, most medical providers are unable to practice the skills needed for vaginal breech delivery so most providers are not comfortable with these techniques. Because of increased risk to the baby, possible inexperience and the possibility of lawsuits, cesareans are usually performed.

There are doctors who perform breech deliveries in the hospital. If this is your choice, I will make every effort to facilitate this choice.

My practice guidelines include the right of the client to choose to continue care with me and decline referral to a doctor, following a complete discussion of the risks involved my experience level, and the signing of this consent form.

Breech presentation is considered a normal variation in pregnancy, occurring in 3-4% of term deliveries. Slant board, homeopathic pulsatilla, and moxibustion (a Chinese medicine form) are our first choice to change a breech to a head-down position. If the baby remains breech, please consider the following.

Risks include increased fetal morbidity and mortality (injury and death) due to the following:

Trauma and injury to the baby as a result of 

* normal swelling and bruising of the baby's presenting parts during labor and delivery
* delivery techniques and manipulations during the birth process causing fractures of the skull, neck, humerus, clavicle and femur
* spinal cord injuries
* damage to internal organs if the baby is grasped incorrectly.

Asphyxia due to

 
* prolonged compression of the umbilical cord during delivery
* actual prolapse of the cord
* aspiration of amniotic fluid caused by breathing before the head has been born
* prolonged or hard labor.

Cerebral hemorrhage due to compression and rapid decompression of the head at delivery.

There is an increased need for resuscitation of the newborn who birthed breech as opposed to head first.

These risks may be minimized by some of the following techniques:

Early detection and assessment of labor.

Close observation and monitoring throughout the labor process.

Intact membranes if possible.

Direct communication between midwife & client as to labor status and coaching

aids

Client cooperation in delaying pushing efforts until complete dilation is achieved.

Clients full cooperation with instructions given during the actual delivery process

My protocol for attending a home breech birth includes all of the following:

1) The baby must be frank breech (butt first, feet in the top of the uterus).

* Sonogram done prenatally by 37 weeks to rule out anomalies that sometimes are associated with breech presentation.
* Head flexed
* Distance to hospital <30 minutes
* Pelvis adequate for fetal size
* Gestational age >37 ½ weeks, <41 ½ weeks
* Psycho-social aspects conducive to cooperation during labor & delivery
* Signed informed consent
* Following rupture of membranes labor should begin within 6 hours, as the decrease in amniotic fluid makes cord compression more likely
* Once labor has begun, progress should be within normal limits.

In the presence of problems above, the hospital and even a cesarean section should occur for the baby's safety.

"My Midwife has explained this situation in writing (by this form) and verbally (using books, photos and videos). I understand that my full cooperation will be necessary to aid in avoiding complications."

Date Initials

________ _________ I have been informed of my Midwifes breech experience:

_______breech assistance ________supervised _______on her own

_______ _________ I will make every effort to cooperate in order to facilitate a normal breech delivery of my baby

_______ _________ I am aware that at any time I may choose to re-evaluate my options and be referred/transported to another care provider (provided birth is not imminent)

______ _________I realize that if at any time a situation arises that requires immediate emergency care, my midwife will inform me, and transport may be appropriate.

______ ________ Other options discussed: __________________________________________________

After careful evaluation of the above, I am exercising my right to choose to birth my breech baby at home and waive referral to another provider. This decision is made of my own free will and I absolve and hold harmless my midwife.

Signed_____________________________________________date_____________

Midwife signature___________________________________________

Witness____________________________________________________________