as posted on www.nursingbirth.com.
Nowhere near a very safe or easy way to birth.
Consent for Elective Primary Cesarean Section
A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.
I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.
(Print Patient Name)
Patient’s Initials
_____ I have informed the doctor of all my known allergies.
_____ The details of the procedure have been explained to me in terms I understand.
_____ Alternative methods and their benefits and disadvantages have been explained to me.
_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:
* Pain or discomfort
* Wound infection; and/or infection of the bladder or uterus.
* Blood clots in my legs or lungs
* Injury to the baby
* Decreased bowel function (ileus)
* Injury to the urinary tract of GI tract
* Increased blood loss (2x that of a vaginal delivery)
* Risk of additional surgeries
* Post surgical adhesions causing pain/complications with future surgeries
* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization
_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.
_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to:
* Placenta previa, where the placenta covers the cervix.
* Placenta accreta, where the placenta grows into the muscle of the uterus.
* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.
* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.
_____ I have been informed of what to expect post-operatively, including but not limited to:
* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.
_____ The doctor has answered all of my questions regarding this procedure.
_____ I am aware and accept that no guarantees about the results of the procedure have been made.
I certify that I have read and understand the above and that all blanks were filled in prior to my signature.
________________________________ Patient Signature/Date
________________________________ Witness Signature/Date
I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.
