Consent Forms


Download the consent forms commonly needed by
Vancouver Island mothers during pre-natal care.

Gestational Diabetes Mellitus (GDM)

Download the consent form in PDF

Gestational Diabetes Mellitus (GDM)

What is GDM?

In approximately 3-5% of pregnancies the mother may develop Gestational Diabetes Mellitus, or GDM. This is a condition in which blood sugar is abnormally elevated during pregnancy and generally develops because the pancreas cannot meet the extra requirements for insulin. Signs and symptoms of GDM are mild and mimic other signs of pregnancy: increased thirst, hunger, and urination. Women with GDM are at increased risk for infections, elevated blood pressure, and problems that accompany the delivery of a large baby, such as tissue trauma and/or stuck shoulders.

Infants born from diabetic mothers may need to have their blood sugar levels monitored for the first few days. These babies are more likely to develop low blood sugars as their bodies are now withdrawn from their mother’s continuous high glucose supply and are also more susceptible to jaundice. Problems for the baby are generally related to the degree of severity of GDM in the mother.

Risk Factors for GDM

  • Maternal age of 26 and older.
  • Obesity, determined by a body mass index more than 27 (see instructions below to determine this).
  • Ethnicity: women from Hispanic, African, Native American, South or East Asia, or Pacific Islands ancestry.
  • Previous history of abnormal glucose tolerance.
  • Past poor pregnancy outcome (stillbirth, spontaneous miscarriage, family birth defects).
  • Family history of GDM, or Type 2 diabetes.
  • Previous history of large newborn (more than 4000g or 9lbs).

Other Signs that may point to GDM include:

  • Excess amniotic fluid.
  • A large fetus.
  • Accelerated weight gain.
  • Repeated detection of glucose in the urine, or repeated urinary tract infections. Glucose in the urine during pregnancy is a poor indicator of diabetes. At this time the kidneys have a lower renal threshold for glucose. A high sugar diet is often responsible for high urine glucose.

Testing for GDM

GDM Screening Tests

The screening test is usually done between 24-28 weeks of gestation. This test does not determine if a woman has GDM. It does help the midwife determine if further testing for GDM is required. The Glucose Challenge Test (GCT) involves going to a lab, drinking a very sugary (50g glucose) drink, sitting still for an hour, and then having a blood test that assesses the levels of sugar in the blood.

An alternative is the 2-Hour Postprandial which involves going to the lab for a blood drawn after an overnight fast. Then eating a meal within 15-20 minutes, and returning to the lab 2 hours after beginning the meal. This method of screening is not as accurate as GCT.

The Diagnostic Test: Glucose Tolerance Test (GTT)

A diagnostic test is done if the blood sugar levels on the screening test are elevated. Again the mother goes to the lab (for either 2 or 3 hours), only this time she must fast throughout the night prior to her arrival. An initial blood draw is taken upon arrival. Then either 75 or 100-g of glucose solution is consumed followed hourly by blood tests. From this extensive testing a diagnosis of GDM can be determined. This test is also available for women who were diagnosed with GDM in a previous pregnancy.

What if You Have GDM?

The next step will involve information and instruction on diabetic care such as health teaching on diet, exercise, and monitoring of blood sugars. Very few women will require insulin. Generally, blood sugars returns to normal levels shortly after birth. If a client is found to have GDM the midwife is required by the College of Midwives of British Columbia to consult with other health care professionals regarding future care. The midwife may remain involved with the care but each case will be handled individually.

Occasionally GDM occurs regardless of risk factors or the tests results. This is one of the reasons the midwife will continue to monitor for sugar in the urine, and assess baby’s growth at each prenatal appointment.

Pros and Cons of Testing

Advantages

Women who develop GDM are at a greater risk for developing Type 2 diabetes later in life. Being diagnosed with GDM may encourage these women to develop a healthy lifestyle early on. This may be an effective way to prevent or postpone the onset of Type 2 diabetes later in life.

Disadvantages

Some health authorities question the benefits of diagnosing GDM. There is considerable controversy that exists in the literature about the efficacy and ethics of screening and treatment. The concern is that the diagnosis of GDM comes with an increased likelihood of medical interventions (e.g. induction, caesarean sections), yet there is little information regarding the effectiveness of treatment versus no treatment. Proper diet, exercise, and monitoring of blood sugar may reduce the risk for large babies. However, studies have not proven that these treatments have significant benefits for the outcomes for mothers or their babies.

Information and Recommendations

  • No eating, drinking (water is okay), or gum chewing, or physical activity is allowed at the lab.
  • Unfortunately the GCT screening test has a high false-positive rate (i.e. you’re incorrectly diagnosed as having GDM). The GTT or diagnostic test will clarify the results.
  • The glucola drinks are very sweet and may cause feelings of nausea, and/or dizziness.
  • Prior to testing, try to avoid high sugar foods such as fruit juices, pops, ice tea, cereals, white breads, pasta etc. Protein food sources (eggs, beans, meat, nuts) are preferable and will give a more accurate reading.
  • Women with results greater than 10.3mmol/L on the screening test can be diagnosed with GDM without further testing.
  • Bring some reading material to help pass the time.
  • Optimal Total Weight Gain during pregnancy: first trimester 0.5 to 1 kg (1 to 2 pounds), 2nd and 3rd trimester 0.2 to 0.5 kg (0.5 to 1 pound)/week. The overweight woman should achieve the lower end of the range and the underweight, the higher end of this range. BMI = Body Mass Index. Formula: weight (in kilograms) divided by height (in meters squared). For example, an 85 kg, 170 cm woman has a BMI of 29 (85 divided by 2.89).

Informed Consent or Informed Refusal for Gestational Diabetes Mellitus (GDM) Testing


I, ________________________________________ have read the GDM information sheet, and I understand the information. I have had the opportunity to discuss and research this topic, and the opportunity to ask questions with my midwife. At this time I:

CONSENT _____

DO NOT CONSENT _____

to have the glucose screening test.


If I have the screening test and the results are positive I understand that I will be advised to follow through with the glucose tolerance test in order to better determine if I have GDM. In accordance with the College of Midwives of British Columbia, my midwife will be required to consult with other specialist(s) if I am positively diagnosed with GDM.


Client Signature: ________________________________________

Date: ____________________


Midwife Signature: ________________________________________

Date: ____________________

Group Beta Streptococcus (GBS)

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Group Beta Streptococcus (GBS)

What is GBS?

GBS is a common type of bacteria present in about 30% of adults. This bacteria is found in the rectum, bladder, and also in women’s vaginas. During pregnancy we become more concerned about the colonization of GBS because it can be passed on to the newborn. It is estimated that between 40-70% of GBS positive women will pass this bacteria onto their babies during birth. While the majority of babies are not affected by the bacteria, a very small number (1-2%) of these babies will go on to develop an infection. GBS infected babies may have mild to severe problems which can affect their blood, brains, lungs, or spinal cord. Therefore parents should be informed of this disease, consider GBS screening, and be aware of the recommended course of treatment and knowledgeable in identifying GBS infection in a newborn.

The current standard of care involves determining a woman’s GBS status:

  • Between 35-37 weeks gestation a screening test can be used to identifying women who are colonized with GBS. (It is possible to have a negative test result and still be GBS positive.)
  • To culture for GBS a swab (similar to a Q-tip) is inserted into the lower vagina and rectum and then is placed in a special medium and sent to the lab.
  • A women with GBS in her urine this pregnancy, or who has delivered an infant with GBS disease is recommended to be considered GBS positive.

Women who are determined to be GBS positive will be recommended to have antibiotics.

  • During active labour intravenous antibiotics are given to GBS positive women usually every 4 hours.
  • Although an anaphylactic reaction to antibiotics is rare, women planning a home birth must go to the hospital for their first dose of antibiotics.

If a women’s GBS status is not determined, treatment with IV antibiotics is strongly recommended if there is:

  • Preterm labour (less than 37 weeks),
  • Ruptured membranes for longer than 18 hours,
  • Maternal fever during labour (temperature greater than 38 C orally or 100.4 F),
  • Previous delivery of a newborn with GBS or evidence of GBS urinary infection.

Facts Associated with GBS

Women

  • GBS can trigger premature labour and has also been linked with maternal infection. Including infection of the urinary tract, amnionitis (infection of the bag of waters) endometritis (infection of the uterus).
  • Women who carry GBS but do not develop a fever during labour > 38 C or 100.4 F, have ruptured membranes over 18 hours or have labour or ruptured membranes before 37 weeks, have a relatively low risk of delivering an infant with GBS disease.
  • With antibiotic therapy a mild allergic reaction to penicillin (such as rash) occurs in 1 out 10 women.
  • There is a 1 in 10,000 chance of developing a severe allergic reaction (anaphylaxis). This is a life-threatening condition which requires emergency treatment.

Newborn

  • The likelihood of GBS disease of the newborn is about 2/1000 live births.
  • The likelihood of a GBS positive mother delivering a baby with GBS disease is approximately 1 out of every 100-200 births if no antibiotics are given. This is reduced to 1:4000 if antibiotics are given.
  • Preterm infants and infants weighing less than 2500g have a much higher infection rate.
  • Babies that survive a serious infection with GBS, particularly those who have meningitis, may have long-term problems, such as hearing or vision loss or learning disabilities. Approximately 15-20% of GBS infected babies will not survive.

Alternatives and their Risks/Benefits

Herbal immune enhancing/antimicrobial formulas (e.g.: Congaplex by Standard Brands or EHB by NF Formulas, vaginal suppositories with tea tree oil or colloidal silver) are available. Some have anecdotal evidence of clearing GBS colonization, but no scientific studies are available. Beware of formulas containing Goldenseal as it can induce preterm labour

Signs of GBS infection in the Newborn

GBS is usually present as blood poisoning, pneumonia, or meningitis. Signs of GBS infection usually become apparent within the first two days of life, but may occur within hours of birth. Signs of an infection in a newborn can be difficult to determine. They include lethargy, poor feeding, high/low temperatures, irritability, high/low breathing rates, and breathing difficulties as seen by flaring of the nostril, laboured breathing, grunting noises, and/or a blue appearance.

Informed Consent or Informed Refusal for Antenatal GBS Testing


I, ________________________________________,

CONSENT ____

DO NOT CONSENT ____

to testing for GBS at this time.


I understand that this is a screening test only, that no method of screening and/or prophylactic treatment is 100% effective in preventing GBS. I also understand that GBS screening and prophylactic treatment can reduce the incidence of GBS disease. I have had my questions answered and can make an informed decision regarding GBS testing.


Client Signature: ________________________________________

Date: ____________________


Midwife Signature: ________________________________________

Date: ____________________

Maternal Serum Screen

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Maternal Serum Screen

What is MSS?

The maternal serum screen is a test that involves drawing some of the mother’s blood around 15-20 weeks gestation. Screening is most effective between 16-18 weeks gestation when dates are confirmed by ultrasound. This test screens for three conditions in the unborn baby. The three conditions are Down’s Syndrome, neural tube defects (NTD), and Trisomy 18.

Down’s Syndrome (DS)

Down’s Syndrome is a genetic condition in which the child has an extra 21st chromosome. Around the world DS occurs in approximately 1 in 800 births. The child appears physically different. Facial features vary but may have slanted eyes, a prominent tongue, small ears, and a flat nasal bridge. Children with DS generally have some learning disabilities, and often have other conditions associated with the disease including heart defects, and visual and hearing impairments. Some individuals with DS will lead semi-independent lives while other will be completely dependent as the severity of this condition varies. The likelihood of delivering a child with DS increases with the age of the mother.

Neural Tube Defects (NTD)

About 3 to 4 weeks after conception, a structure known as the neural tube closes to form the brain and the spinal cord. If this tube fails to close, a neural tube defect occurs. This opening can affect the brain and the skull (Anencephaly) or it can affect the spinal cord (Spinal Bifida). Depending on the size and the location of the neural tube defect, some children may experience limited feeling and movement of the lower limbs, loss of bowel and bladder control, and be mentally handicapped. In Canada, approximately 1 newborn out of 750 will have a neural tube defect. Research has shown that if folic acid is added to the diet for a period of time before and during pregnancy, the risk of having a child with neural tube defect is reduced by at least 50%.

Trisomy 18

Trisomy 18 is a rare chromosomal disease. Often the baby does not survive through the pregnancy, or dies shortly after birth.

What the Test Results Mean

The MSS test itself will not tell you for sure if your baby has one of the above conditions. It does however tell you if your baby is more likely to have one of these conditions. The test does this by measuring certain markers in the mother’s blood. These markers are alpha fetoproteins, unconjugated estroil, and human chorionic gonadotrophin. These measurements are compared and considered along with maternal age, weight, race and gestational age. The results you receive will be a numerical equation.

For example, the risk for Down’s Syndrome is 1 in 800; for neural tube defects 1 in 750; and for Trisomy 18, 1 in 8000. If your screen has a lower number (1 in 100 for DS) the screen is considered positive and further investigation will be recommended. It is important to understand that with a positive screen the baby is usually normal. It is also possible to have a negative screen and still have an affected baby. The screen can detect approximately 75% of cases of DS, 85% of open spinal bifida, and 60% of Trisomy 18.

Should your results show a positive screening test, a more diagnostic test will be recommended. Follow-up can involve genetic counseling, ultrasound, or an amniocentesis (a hospital procedure where amniotic fluid is gathered and tested while under ultrasound). What can be very difficult for the family is the waiting period for further tests, and awaiting further test results.

Advantages of Testing

  • Having a negative screen may help some couples feel more relaxed that all is well,
  • Learning that your baby has a certain condition may help the woman (and her partner) prepare more for the birth of a baby with special needs,
  • In some circumstances a woman (and her partner) may decide that they would prefer not to continue with the pregnancy in the event that the child is to have disabilities, or is unlikely to survive.

Disadvantages of Testing

  • A blood draw is required,
  • There is up to a 2 week waiting period for results,
  • Further investigation is recommended with a positive screen to confirm whether or not the condition actually exists,
  • Amniocentesis has a risk of 1-2% of causing a miscarriage,
  • Stress during the waiting period and especially after a positive screen can be draining.

When deciding whether or not to have this test, it is important to consider what you would do with the information you will receive.

Informed Consent or Informed Refusal for Maternal Serum Screening


I, ________________________________________ have read the information above regarding the maternal serum screen. I have also had the opportunity to discuss and ask questions about MSS with my midwife. I understand the information and have decided to:

CONSENT _____

NOT CONSENT _____

to have this test performed.


Client Signature ________________________________________

Date: ____________________


Midwife Signature ________________________________________

Date: ____________________

Newborn Tests and Procedures

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Newborn Tests and Procedures

Newborn Exam

Within a couple of hours of birth, usually after the first feeding, a head-to-toe exam is done of your baby. He or she is measured and weighed. The heart and lungs are listened to, and the baby is checked for any abnormalities from the ears and mouth, to the number of toes. Normal newborn reflexes are checked for – their absence could mean a problem with the central nervous system. Anything unusual is referred to a pediatrician. Feel free to ask questions during the exam, and to touch your baby and talk to him/her. We prefer to start when the baby is calm and are as gentle as possible, but some babies object to the necessary handling and will cry. If a pediatrician has been called to the delivery because we have a concern about the baby’s welfare, the newborn exam will be done by him/her very soon after the birth.

Eye Prophylaxis

Erythromycin, an antibiotic ointment, is routinely applied to babies’ eyes within an hour of birth. Gonorrhea and chlamydia can infect the eyes and cause blindness if untreated. They can be present with no symptoms in the mother, and lab tests occasionally have false negatives.

You may choose to have swabs done during pregnancy to look for gonorrhea and chlamydia, and be treated if either is present. Some parents choose not to expose their newborns to antibiotics. If this is your choice you will need to sign the release below. If you have a hospital delivery a release will need to be signed there as well.


I, _________________________________ choose to use / not use Erythromycin eye prophylaxis


signed__________________________________ date_________________


Vitamin K

Vitamin K is important in blood clotting. It is manufactured in the intestines by bacteria. Babies need to be colonized by the bacteria from their parents and start making their own Vitamin K as soon as possible. A baby with insufficient Vitamin K may develop neonatal hemorrhagic disease – which can range from bruising with normal handling to fatal bleeding. Brain damage can result. Research shows an incidence from 1/500 to 1/1,500. Statistically, breastfed babies have a higher rate of hemorrhagic disease.

You may choose to have your baby receive Vitamin K by a single injection (IM) at the time of the newborn exam, or your baby may receive three doses of Vitamin K by mouth (PO). The first is done within a few hours of birth, the second at 4 -10 days and the third at 4 – 6 weeks. Research supports injectable Vitamin K. Oral Vitamin K appears to work, but doesn’t have extensive research to support it. If you choose not to give your child Vitamin K, an informed choice release is needed.


I, ________________________________ choose to use / not use Vitamin K IM / PO for my baby.


signed_______________________________ date__________________


Neonatal Metabolic Screen

This is a blood test that checks for metabolic problems which could permanently damage your baby: phenylketonuria (PKU), hypothyroidism, galactosemia and MCAD. If these problems are caught early and treated your baby can avoid harm.

Phenylketonuria is an inability to metabolize a protein. Abnormal amounts build up in the body and can damage the brain. The incidence in B.C. is 1/18,000 live births. Treatment is a special diet low in phenylalinine. Your baby may be able to receive some breast milk, depending on the severity of the disease.

Hypothyroidism is an abnormally low production of thyroid hormones. These are important for normal brain development. The incidence in B.C. is 1/3,000 births. Treatment is a daily dose of thyroid medication.

Galactosemia is an inability to break down the milk sugar galactose. Galactose builds up in the body causing failure to thrive, jaundice, vomiting, diarrhea, liver damage, hypoglycemia, cataracts and mild to moderate brain damage. The incidence in B.C. is 1/25,000 newborns. It is treated by a special diet with no lactose.

Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCAD) causes problems with fat metabolism. It can cause hypoglycemia and sudden unexpected death. It is found in 1/20,000 infants. Treatment is a special diet and supplements.

The test is done by warming the infant’s foot (to bring blood close to the surface) and then pricking the heel. Sometimes the baby must be pricked more than once to get enough. Blood is collected in four circles on blotter paper. The paper is dried and sent to a lab in Vancouver for testing. There is not an alternative test and once symptoms of these diseases are noticeable irreversible damage may have been done.

The best time to do these tests is 24 – 48 hours after the birth. A test done before 24 hours will need to be repeated. If you have an early discharge from the hospital and wish to have your midwife do the test in your home the next day you will have to sign a form saying you are deferring the test. Of course, if you have a home birth, the test will be done in your home. You can hold and comfort, or nurse, the baby while the test is being done. Most babies cry briefly but aren’t upset for long.

Circumcision

Medical societies like the Canadian Pediatric Society and the American Academy of Pediatrics have advised since the 1970s that routine circumcision of infants be discontinued. Newborn circumcision is no longer done in the hospital. It is not covered by medical insurance and will cost over $100. It is considered cosmetic surgery as there is NO medical reason for circumcising a newborn. There are only three doctors in Nanaimo that will perform a circumcision – some will only do it for families already in their practice.

Circumcision carries risks – as any surgical procedure does – including infection, excessive bleeding and scarring. Baby boys are strapped down on a board. Local anesthetic is usually used, but there will be pain (the penis is well supplied with nerves) when the anesthetic wears off.

If you choose to circumcise an infant son for religious or personal reasons, please organize the surgery during your pregnancy.

Rh Immune Globulin

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Rh Immune Globulin

Why is Rh Negative Blood a Concern?

About 15% of the population (less in African-Americans or Asiatic populations) have Rh- blood. When a woman has Rh- blood and her partner has Rh+ blood, serious problems can develop. This is because the baby will more than likely inherit the more common blood type, which is Rh+. When the baby’s blood enters the mother bloodstream her body will see it as a foreign invader. Normally when the body does not recognize a substance, it will make antibodies to protect itself. These antibodies cross over the placenta and into the baby’s bloodstream. Once these antibodies are in the baby’s blood they will attack the baby’s red blood cells.

Normally, the mother’s first child is not seriously affected by this condition. First children may have conditions that are less severe such as anemia (low blood counts), or jaundice. This is because the main time for exchange of blood occurs during birth of the baby, and the mother is most likely to develop antibodies after the birth. That is why more severe effects generally occur in second, and subsequent pregnancies. Depending on the severity of the condition, and if left untreated, this condition can cause problems for the baby in the liver and spleen, heart failure, and can be responsible for the death of the baby. Fortunately there is something that can be done to prevent these complications.

Rh (D) Immune Globulin

Rh (D) IG was discovered in 1970 as a way of preventing the complications that occur when the mother’s Rh factor is a concern. The product is a substance that is taken from another human who has already developed Rh antibodies. These antibodies are injected into the mother so the mother’s body no longer needs to develop these antibodies to fight the invasion.

When is Rh (D) IG given?

It is recommended that the mother receive Rh (D) IG (300 mcg dose) at least twice: once at 28 weeks gestation, and again within 72 hours after birth of the baby if the baby is determined to be Rh+ (by an umbilical cord blood test). Rh (D) IG may be given at a later point after the birth, but may not be as effective. Other times Rh (D) IG are recommended include miscarriages, abortions, ectopic pregnancies, chorionic villus sampling, amniocentesis, external cephalic version (turning breech babies), abdominal wall trauma, placenta previa (placenta located over cervix), placental abruption (placenta separates from the uterus), or any other condition in which fetal blood may enter the mother’s bloodstream.

Safety and Alternative

The side effects of Rh (D) IG when given in the muscle are rare and usually mild. Possible side effects include discomfort at the injection site, and a slight temperature elevation. Rarely a woman might feel muscle soreness, fever, feelings of illness, enlargement of spleen, and possibly an increase in bilirubin concentrations. Safety of the 28 weeks gestation injection has not been tested. However, no increase in newborn jaundice has yet been observed. Alternatives to this immunization are still being tested but at present Rh (D) IG appears to be the most effective at preventing.

RhIG Effects

RhIG reduces, but does not eliminate the possibility of Rh sensitization. The percentage risk of sensitization after birth are thought to be:

  • 7-17% without treatment
  • 1-2% with postpartum treatment
  • 0.1-0.2% with antenatal and postpartum treatment

Informed Consent or Informed Refusal for Rh Immune Globulin


I, _________________________________________ have read the Rh Immune Globulin information sheet and I understand the information. I have had the opportunity to discuss and research this topic, and the opportunity to ask questions with my midwife. I hereby:

CONSENT ____

DO NOT CONSENT _____

to have the RhIg treatment performed.


I would like it administered:

PRENATALLY ____

POSTPARTUM ____

as necessary.


Client Signature: ___________________________________________

Date: _____________________


Midwife Signature: ____________________________________________

Date: _____________________

Consent to Transfer Records

Download the consent form in PDF

Consent to Transfer Records


Jennifer Hewko, Registered Midwife
3799 Avonlea Drive, Nanaimo, BC V9T 6R1
Phone/Fax (250) 760-1080

To:

Health Care Provider: ___________________________________

Phone/FAX: _______________________


From:

Client Name: ____________________________________________ Date of Birth: _____________________

PHN: _____________________ Past Pregnancy: YES ____ NO ____


I, _____________________________________ am requesting midwifery care during this pregnancy and birth. Please fax a copy of all pertinent records (prenatal records, lab reports, ultrasounds, and birth summaries any previous pregnancies to the number listed above. I hereby authorize the release of my records as listed above to ___________________________________.


Signature: ___________________________________

Date: _____________________


If _____________________________________ is accepted into midwifery services, her maternity care will continue until the sixth week postpartum. At that time, copies of prenatal and/or birth records can be forwarded on request. In the event that concerns develop outside the scope of midwifery practice guidelines, consultation, or transfer of care will occur as set forth by the College of Midwives of British Columbia.

Thank you,

Jennifer Hewko, RM

The material on this website is intended for information use only. Any individual with health concerns should contact their health care provider for a complete diagnosis. Do not depend solely on the content of this website for treatment.

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