BORN TO BE LOVED
Born To Be Loved Birth ~ Faith Morie CPM LM
~ VBAC Informed Choice and Disclosure Statement ~
Faith Elizabeth Morie CPM LM
11617 South Mulberry Court Jenks, OK 74037
email@example.com ~ Phone: (918) 284-3609 ~ Fax: (855) 701-3163
I have had ______ previous cesarean section(s) and desire a Vaginal Birth After Cesarean (VBAC) with my current pregnancy.
I have been informed by my midwife that the American College of Obstetricians and Gynecologists (ACOG) guidelines (2010) concerning VBAC state that:
The concept of routine repeat cesarean birth should be replaced by a specific decision process between the patient and the physician for a subsequent mode of delivery.
In the absence of a contraindication, a woman with one previous cesarean delivery with a lower uterine segment incision should be counseled and encouraged to undergo a trial of labor in her current pregnancy.
A woman who has had two or more previous cesarean deliveries with lower uterine segment incisions and who wishes to attempt a vaginal birth should not be discouraged from doing so in the absence of contraindications.
A trial of labor and delivery may be planned to take place in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk.
My midwife has counseled me regarding the benefits of VBAC. I understand that VBAC has a number of benefits over repeat cesarean section and that for most women, in an appropriate setting, these benefits outweigh the risks. These benefits include the elimination of operative and postoperative complications with a successful VBAC, a reduction in the length of postpartum recovery, easier infant care and bonding, and many emotional and mental benefits.
My midwife has also counseled me concerning the risks that are involved in choosing to VBAC – the main risk being uterine rupture, which although rare, can be catastrophic in a matter of minutes. I understand that significant rupture only occurs in less than 1% of appropriately attempted VBACs (no labor-altering medications given during labor). But that when rupture does occur, it can lead to excessive blood loss, damage to, or death of the infant, and/or damage to, or death of the mother.
I have also been informed by my midwife, that the current medical practice standards and principles as stated by the ACOG recommend that VBACs occur in a hospital setting. I understand that these standards and principles require that my midwife transfer my care to a physician, unless a physician approves me to VBAC with my midwife, or unless I voluntarily waive medical transfer.
After receiving counseling from my midwife concerning the above, having my questions answered, and understanding what I have been told,
I voluntarily waive transfer of my care to a physician for VBAC and choose to continue care with Faith Morie CPM, LM.
Mother ________________________________________________________ Date __________________
Father ________________________________________________________ Date __________________
Midwife ________________________________________________________ Date __________________