The Informed Consent Form is a one-page document of the Midwifery Advisory Council, published through the Delaware Division of Professional Regulation, that clients contemplating home birth complete with their midwife. It records that the client understands the risks of midwifery care and home birth, consents to care for herself and her newborn, and has been told which facility would receive her in a transfer. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by the Division at dprfiles.delaware.gov.
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What is Informed Consent – Delaware?
The Informed Consent Form of the Midwifery Advisory Council is the Delaware document that a client contemplating home birth completes to acknowledge the nature and risks of midwifery care at home and to consent to that care for herself and her newborn.
The form is printed on the letterhead of the State of Delaware Board of Medical Licensure and Discipline and is available through the Delaware Division of Professional Regulation. It is not a general medical consent form: it is specific to home birth with a midwife. It contains seven statements, each with a box to check:
- a midwife is not a licensed physician or nurse, and the client is not seeking the services of either for the home birth;
- home birth can include increased risk of death and disability for mother and child;
- the risks of midwifery care and home birth have been explained and are understood;
- consent to midwifery care during labor, birth and postpartum in a home setting;
- the midwife's assessment, monitoring and support of the newborn after birth, with the care listed on the form (including APGAR scores, a newborn physical exam, eye prophylaxis and Vitamin K, orally or intramuscularly);
- the recommendation that every newborn see a pediatrician within 72 hours of delivery;
- the possibility of transfer, with the receiving facility, its approximate distance from the planned birth location, its concurrent care policies and the client's designated agent written in.
The client and the midwife both sign and date it. The printed revision is Revised 4/2019. The form prints no form number.
Who needs to file Informed Consent – Delaware?
The form says it is to be completed by all clients contemplating home birth. In practice that means the person planning to give birth at home with a midwife, who checks each box and signs, together with the midwife, who also signs and dates it.
Points the form itself makes:
- Clients: every box must be checked. The form states that it covers care for the client and her newborn during labor, birth and postpartum in a home setting.
- Midwives: the midwife signs and dates the form under the client's signature.
- Designated agent: if the client is incapacitated during a transfer, the statement on the receiving facility's concurrent care policies is repeated orally to the agent the client names on the form. The client chooses that person in advance and writes the name in.
The form is not meant for births in a facility. It addresses only home birth with a midwife, and the form states that the client is not seeking the services of a doctor or nurse for that birth. It prints no rules about minors or signing for another person.
When to file Informed Consent – Delaware
Complete the form when you are contemplating home birth with a midwife: it is addressed to all clients in that position. It carries no due date and no expiration date; the only date it prints is the revision, 4/2019, and a line beside each signature for the date it is signed.
The transfer section looks ahead to labor and birth. The facility, distance and concurrent care details are filled in before any transfer, and the form says the concurrent care statement will be repeated orally to you, or to your designated agent if you are incapacitated, if a transfer happens.
Because the form is signed by both you and the midwife, plan to complete it at a visit where both can sign.
How to fill out Informed Consent – Delaware
Read the form and check boxes
The form states it is to be completed by all clients contemplating home birth and says to check each box. Read every statement before you check its box.
Acknowledge midwife role and risks
Check the first three boxes: a midwife is not a licensed physician or nurse, home birth can include increased risk of death and disability for mother and child, and the risks have been explained to you and you understand them.
Give consent to midwifery care
Check the box that begins "I, the undersigned, consent to receive midwifery care" for yourself and your newborn during labor, birth and postpartum in a home setting.
Acknowledge newborn care and pediatrician advice
Check the box describing the midwife's assessment, monitoring and support of the newborn, then the box about seeing a pediatrician within 72 hours of delivery.
Enter the receiving facility
In the transfer box, write the name of the receiving facility on the line after "the receiving facility will be".
Enter the distance
On the line marked (distance), write the approximate distance from the receiving facility to your planned home birth location.
Write the concurrent care policies
Under "The concurrent care policies at the receiving facility are as follows", enter the policies on the two lines provided.
Name your designated agent
Write the person who would hear the concurrent care statement if you were incapacitated during a transfer, on the line after "My designated agent for this purpose is".
Sign and date as client
Enter your signature and the date on the Client Signature and Date line.
Have the midwife sign and date
The midwife signs and dates the Midwife Signature line. Both signatures are printed on the form.
Review and download the completed PDF
Check that every box is marked and the transfer details are complete, then download or print the completed PDF from FillingPDF and handle it as described under How to submit.
How to submit Informed Consent – Delaware
The form itself names no recipient, mailing address, portal or deadline for returning it. What it does print is a signature line for the client and one for the midwife, so the completed form is a document the two of you sign together.
For questions about what to do with the signed form, contact the Delaware Division of Professional Regulation, the issuer printed on the form:
- Phone: (302) 744-4500
- Fax: (302) 739-2711
- Email: [email protected]
- Mail or in person: Cannon Building, 861 Silver Lake Blvd., Suite 203, Dover, Delaware 19904-2467
- Website: DPR.DELAWARE.GOV
The Division's forms page explains that its applications and service requests are processed in its online licensing portal, DELPROS, that some forms are uploaded there and others are mailed, and that the instructions in DELPROS control. If your midwife is submitting this form as part of a licensing request, follow those directions.
FillingPDF lets you fill out and download the PDF; submission follows the agency's channels above.
Common mistakes to avoid
- Leaving a box unchecked: the form says to check each box.
- Checking the box that says the risks have been explained and understood before the midwife has explained them to you.
- Leaving the receiving facility blank in the transfer statement, or writing a facility without the approximate distance from the planned home birth location.
- Skipping the lines for the receiving facility's concurrent care policies.
- Not naming a designated agent, the person who hears the concurrent care statement if you are incapacitated during a transfer.
- Signing without the date, or sending the form with only the client signature or only the midwife signature; both signature lines and both dates are printed.
- Treating the form as a medical consent for hospital or physician care: it covers midwifery care and home birth only.
Frequently asked questions
What is the Delaware informed consent form for home birth?
It is the Informed Consent Form of the Midwifery Advisory Council, revised 4/2019. Clients contemplating home birth check each box to acknowledge the risks and consent to midwifery care for themselves and their newborn, and the client and midwife both sign.
Who has to complete the Informed Consent Form?
The form says it is to be completed by all clients contemplating home birth. The client checks each box and signs; the midwife then signs and dates it on the line printed below the client's signature.
Can I fill out the informed consent form online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent of the Delaware Division of Professional Regulation and does not file or send the form; you and your midwife sign it and handle it through the agency's channels.
What do I write in the transfer section?
Write the name of the receiving facility, its approximate distance from your planned home birth location, and the facility's concurrent care policies on the two lines provided. Also name your designated agent, who hears the concurrent care statement if you are incapacitated.
Does the form say a newborn must see a pediatrician?
It says it is recommended that every newborn see a pediatrician within 72 hours of delivery. By checking the box you state that you understand this recommendation; the form does not set a requirement beyond that wording.
What newborn care does the midwife provide according to the form?
The form lists assessing newborn well-being, vital signs, color, tone and reflexes, APGAR scores at 1 and 5 minutes (and 10 minutes when indicated), temperature, feeding, bowel and bladder function, cord clamping and cutting, a physical exam, eye prophylaxis and Vitamin K, orally or intramuscularly.
Where do I send the signed informed consent form?
The form prints no return address or portal. Contact the Delaware Division of Professional Regulation at (302) 744-4500 or [email protected], or at 861 Silver Lake Blvd., Suite 203, Dover, Delaware 19904-2467, to ask how the signed form should be handled.
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