BABS

Birth and Baby Services

Offering low-cost & no-cost birth doula services

602-321-0074

Copy and paste this form to print

Evidence Based Birth has created this form to use when you go to the hospital in labor during this time of Covid-19. This form states that if the pregnant person tests positive for Covid-19, that their newborn will not be separated for them.

Informed Consent Form for Refusal of Separation from Newborn Infant

Informed Consent Form for Refusal of Separation from Newborn Infant

I, _______________________________, have been advised by ___________________ that:

• I am a person under investigation for COVID-19 or

• I have a confirmed diagnosis of COVID-19 or

• My newborn infant is a person under investigation for COVID-19 or

• My newborn infant has a confirmed diagnosis of COVID-19

_______________ has recommended that my newborn infant __________________ and I be isolated and separated from each other during hospitalization. The recommendation is based on clinical considerations that have been discussed with me in detail: ______________________________________________________________¬¬¬¬¬¬¬¬¬¬¬¬¬_______________________

____________________________________________________________________________________.

The CDC’s Considerations for Inpatient Obstetric Healthcare Settings (revised April 4, 2020) state,

“The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintaining infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear.”

“The determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case-by-case basis using shared decision-making between the mother and the clinical team. Considerations in this decision include:

• The clinical condition of the mother and of the infant

• SARS-CoV-2 testing results of mother (confirmed vs. suspected) and infant (a positive infant test would negate the need to separate)

• Desire to feed at the breast

• Facility capacity to accommodate separation or colocation

• The ability to maintain separation upon discharge

• Other risks and benefits of temporary separation of a mother with known or suspected COVID-19 and her infant”

“If separation is not undertaken, other measures to reduce the risk of transmission from mother to infant could include the following, again, utilizing shared decision-making:

• Using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the mother.

• Mothers who choose to feed at the breast should put on a face mask and practice hand hygiene before each feeding.

• If the mother is not breastfeeding and no other healthy adult is present in the room to care for the newborn, a mother with known or suspected COVID-19 should put on a face mask and practice hand hygiene before each feeding or other close contact with her newborn.

• The facemask should remain in place during contact with the newborn. These practices should continue while the mother is on Transmission-Based Precautions in a healthcare facility.”

I understand that the World Health Organization does not recommend separation when either the mother or the newborn has a suspected or confirmed case of COVID-19.

The World Health Organization’s Q & A on COVID-19, pregnancy, childbirth, and breastfeeding (dated March 18, 2020) states:

“Can I touch and hold my newborn baby if I have COVID-19? Yes. Close contact and early, exclusive breastfeeding helps a baby to thrive. You should be supported to breastfeed safely, with good respiratory hygiene; hold your newborn skin-to-skin, and share a room with your baby. You should wash your hands before and after touching your baby, and keep all surfaces clean.”

“Can women with COVID-19 breastfeed? Yes. Women with COVID-19 can breastfeed if they wish to do so. They should: practice respiratory hygiene during feeding, wearing a mask where available; wash hands before and after touching the baby; routinely clean and disinfect surfaces they have touched.”

_________________ has fully explained to me the nature, purpose, risks, and benefits of the proposed separation, the possible alternatives thereto, and the risks and consequences of not proceeding, as well as their recommendation to be separated from my infant.

I nonetheless refuse to consent to the proposed separation from my infant.

While we are both inpatients, I will co-locate or “room-in” with my infant. My infant will be discharged to my home with me.

I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.

I hereby release the hospital, its employees and medical/nursing staff, medical students, the attending physician, and any physician involved in my or my baby’s care from any liability for ill effects, including infection, injury, or death to me or my infant that may result from my decision to refuse to consent to the proposed separation.

I confirm that I have read and fully understand the above and that all the blank spaces were completed prior to my signing.

Birthing Patient* _______________________________________________________

Signature, Print name, Date

Other Parent ____________________________________________________________

Signature, Print name, Date

*The signature of the patient must be obtained unless the patient is a minor or is otherwise incompetent to sign. If signed by any person other than the patient, you must note the relationship.

Witness: _______________________________________________________________

Signature, Print name, Date

Provider Certification

I hereby certify that I have explained the nature and purposes of, and alternatives to, the proposed separation mentioned above, and the risks and consequences of not proceeding, including the risk of infection, injury, and death. I have offered to answer any questions and have fully answered all such questions. I believe that the patient/relative/guardian fully understands what I have explained and answered.

Provider: _______________________________________________________________

                Signature, Print name, Date