Newborn- informed consent.doc

The State of New Mexico, Department of Public Health requires the **************************************************************************************A.
Neisseria gonorrhoeae bacteria, chlamydia trachomatis, or anyother bacterial infections present at time of birth can cause eyeinfections in the newborn.
Undetected infection can lead to conjunctivitis, scarring of thecornea, or even blindness in newborns.
Application of the antibiotic Erythromycin in the eye within 2 hoursof birth can reduce this risk of infection.
Side effects of antibiotic use include inability to focus, edema, andinflammation, which usually disappear in 24-48 hours.
_____I understand the risks associated with the possibility of newborn eyeinfections that are untreated. I want to have erythromycin applied to my baby’seyes.
_____I understand the risks associated with the possibility of newborn eyeinfections that are untreated. I DO NOT want to have erythromycin applied to mybaby’s eyes.
Client Signature: ________________________________Date: _________ Midwife Signature: _______________________________Date: __________ In recent years medical science has discovered, by testing the blood of newborn infants, that certain diseases caused by inborn errors of metabolismcan be detected and treated, thus allowing many children who would otherwisebe permanently impaired to develop into healthy children. Beginning January2007, the state of New Mexico is testing for 26 metabolic disorders, including: Fatty Acid Oxidation Disorders (FAO)Carnitine update defectLong-chain L-3-OH acyl-CoA dehydrogenase deficiencyMedium-chain acyl-CoA dehydrogenase deficiencyTrifunctional protein deficiencyVery long-chain acyl-CoA dehydrogenase deficiency Amino Acid DisordersHomocystinuriaTyrosinemia type IPhenylketonuria (PKU)Argininosuccinic academiaCitrullinemiaMaple syrup urine disease Organic Acidemia Disorders3-OH 3-CH3 glutaric aciduria3-methylcrotonyl-CoA deficiencyMitochondrial acetoacetyl-CoA thiolase deficiencyIsovaleric acidemiaMultiple carboxylase deficiencyProponic acidemiaMethylmalonic acidemiaGlutaric acidemia type I Other DisordersCystic fibrosisHb S/beta-thalassemiaCongenital Adrenal HyperplasiaSickle Cell anemiaCongenital hypothyroidismGalactosemiaBiotinadase deficiency A child with one of these diseases usually appears normal at birth. The age when symptoms appear varies with the disease. By using this earlyscreening test, a diagnosis may be made and early medical management can be started. The State of New Mexico requires all newborn infants to bescreened twice - once between 24 and 72 hours and the second time between8 and 15 days old. I have read information about each of these metabolic conditions and understand the risks associated with them. Cost for 1 or both tests is $89.00Payable to New Mexico Department of Health Children’s Medical Services.
_____I choose to have both newborn screenings done at the timingrecommended by the State.
_____I choose NOT to have either newborn screening done.
_____I choose to have only 1 newborn screening done when my baby is _____ Client Signature: ___________________________________ Midwife Signature: __________________________________ *********************************************************************************C.
Intervention programs on infant hearing loss are more effective the earlier the diagnosis. At present, all babies born in the hospital in the State ofNew Mexico are required to have a hearing screen before discharge. Babiesborn at home are also encouraged to have early hearing screening, but as yetthe infrastructure is not set up to facilitate this process.
_____I have been given information on newborn hearing screening.
505-476-8868 (phone); Client Signature: _________________________________Date: __________ Midwife Signature: ________________________________Date: __________


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