VAGINAL BIRTH AFTER
CESAREAN SECTION PATIENT CONSENT FORM
NOTE TO PATIENT: As you may know, there are risks
in any medical, surgical procedure or treatment. Just being
pregnant carries some risks as there are risks in everyday
activities such as driving. The following check list is
designed to help you to make an informed decision as to
attempt to deliver "normally" after you had a prior cesarean
section. This procedure medically is called a Vaginal Birth
After Cesarean section and is abbreviated "VBAC". Your other
option is to have a repeat cesarean section. Please discuss
the contents of this form with your physician, initial off
on each section and choose your option of attempting a VBAC
or a repeat cesarean section to deliver your baby.
(*Birthrites'
Convenor - Hi! I do not think this form is necessary
for having a VBAC, and it may be considered very negative
and disempowering to some women, but if it would make your
Obstetrician happy to see that you understand the risks
involved and are making an "informed" decision in regard to
your VBAC, then I can see that it may be useful in this
respect. I will add some personal comments to this form, in
this colour of text, that may be deleted if the form is used
by copying the form into a processing file and then printing
it. In fact, I would recommend you do delete them... As they
may get your Ob. a bit defensive.
Another form has been produced, by
Dr. Bruce Flamm, which is a little more 'positive' in it's
exploration of women's rights to make that final choice of
method of birth - VBAC vs caesarean. It outlines the risks
involved and in doing this, encourages informed consent.
This form can be found at http://www.vbac.com/
under the "Making Informed Decisions" page of this website.
It is worthwhile comparing the two forms.)
Patient's Initials
1. I understand that I have had one or more prior
cesarean(s). _________
2. I understand that I have the option of an
elective repeat cesarean or to attempt a vaginal birth after
a cesarean (VBAC). _________
3. I understand that approximately 70% of women
who undergo a VBAC will successfully deliver vaginally.
_________ (This percentage increases
in relation to the amount of support women receive in making
the decision to try a VBAC).
4. I understand that VBAC carries a lower risk to
me than a cesarean delivery. The benefits of a successful
VBAC include decreased blood loss, decreased post delivery
complications and a shorter recuperative period.
_________
5. I understand that the risk of a uterine rupture
during VBAC in someone like me who has had a prior incision
in the noncontracting part of my uterus is around 1%.
__________ (* ie, 99% chance of
everything going right... Is the glass half empty or half
full???)
6. I understand that VBAC is associated with a
higher risk of harm to my baby than to me. __________
(* ie, I also understand that a
elective c/section, for no reason, has a much greater risk
to my baby than a well-planned VBAC)
7. If my uterus ruptures during my VBAC, I
understand there may not be sufficient time to operate and
prevent death or permanent brain injury to my baby.
__________ (* Note, The chance of this
happening is very small, and "catastrophic" ruptures are
usually associated with artificial induction/augmentation of
labour. If rupture does occur, it is usually a small opening
along the scar-line, and is generally termed a dehiscense -
a much less "scary" word).
8. The exact frequency of death or permanent
neurologic injury to the baby when the uterus ruptures is
uncertain, but has been reported to be as high as 50%.
__________ (* I would personally like
to view the results of this study, and would recommend that
this statement is removed from the final form, because of
the extremely negative connotations it presents).
9. The risks to me after rupture of the uterus
include but are not limited to hysterectomy (loss of the
uterus), blood transfusion, infection, injury to internal
organs (bowel, bladder, ureter), blood coagulation problems
or death. __________ (* All of these
risks, and more, are involved with caesarean birth of your
child)
10. Probable contraindications to VBAC include
previous classical uterine incision, multiple gestations and
breech. __________
11. Also excluded from considerations for VBAC are
patients unwilling to assume the added risks associated with
a trial of labor for themselves and their baby.
__________
12. I understand that during my VBAC, the use of
oxytocin (Pitocin), a hormone, to make my uterus contract,
may be necessary to assist me in my vaginal delivery. There
may be increased risk with the use of oxytocin during VBAC.
__________
(* Please do not even consider the use
of oxytocin during your labour!!! Visit the page on this
website: Induction
or Augmentation of Labour Especially During a
VBAC)
13. I understand that if I choose a VBAC and end
up having a cesarean during labor, I have a greater risk of
problems than if I had an elective repeat cesarean.
__________ (* But I may also have
greater "peace of mind" and less emotional trauma, as I will
know the caesarean will have been necessary, and that I was
involved in the decisions surrounding it).
14. I have read or have had read to me the above
information and I understand it. I have had all my questions
answered and I have received all the information I need to
make an informed choice, after discussing my options with my
Doctor. __________
I want to attempt a VBAC
___________________________________
___________________________________
(Patient's Signature) (Date) (Time)
OR
I want a repeat cesarean
_____________________________________
____________________________________
(Patient's Signature) (Date) (Time)
Patient Printed Name:
______________________________________
Witness: _________________________________________
___________________________ ________________
(Signature) (Print Name) (Date)
Adapted with permission from OBG Management, November,
1996, Dowden Publishing Co.
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