PLACE LABEL HERE
EXTERNAL CEPHALIC VERSION
INFORMED CONSENT
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
PATIENT NAME: ___________________________________
DATE: ________________
TIME: ________________
The diagnosis requiring this procedure is Pregnancy where the fetal presentation is non-vertex (the
head of the infant is not presenting first).
The nature of the procedure is to attempt to change the position of the fetus to vertex (head first) by
applying external pressure around the abdomen.
The purpose of this procedure is to change the infant’s position to vertex (head first).
This procedure involves the material risk of infection, allergic reaction, severe loss of blood,
loss or loss of function of any limb or organ, paralysis, paraplegia or quadriplegia, disfiguring
scar, brain damage, cardiac arrest or death.
ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks
involved in this procedure including, but not limited, to the following:
 Possible preterm contractions/labor
 Possible premature rupture of membranes with or without cord prolapsed
 Possible injury to the fetus
 Possible bleeding secondary to placental abruption
 Possible fetal distress with need for immediate delivery
 Possible need for immediate surgery, i.e. cesarean section
 Possible unsuccessful version
The likelihood of success of this procedure is:  Good
 Fair
 Poor
THE PRACTICAL ALTERNATIVES TO THIS PROCEDURE ARE:
 To attempt a vaginal breech delivery.
 To perform a cesarean section.
 No intervention.
If I choose not to have the above procedure, my prognosis (future medical condition) is:
Increased risk to mother and/or infant, e.g. head entrapment with vaginal breech delivery, surgical
risks with cesarean section.
I understand that during the course of the procedure described above, it may be necessary or
appropriate to perform additional procedures that are unforeseen or not known to be needed at the
time this consent is given. I consent to and authorize the persons described herein to make the
decisions concerning such procedures. I also consent to and authorize the performance of such
additional procedures, as they deem necessary or appropriate.
I consent to diagnostic studies, tests, x-ray examinations and any other treatment or courses of
treatment relating to the diagnosis or procedures described herein.
*2-18096*
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FORM 2-18096 REV. 10/2013
Page 1 of
PLACE LABEL HERE
EXTERNAL CEPHALIC VERSION
INFORMED CONSENT
I consent to the use of sedation and/or anesthesia as planned by my treating physician. The risks,
benefits and alternatives of such sedation/anesthesia have been explained to me. I understand that
specific risks of anesthesia/sedation include, but are not limited to, changes in blood pressure,
allergic reaction, difficulty breathing, cardiac or respiratory arrest, seizure, coma and death.
I consent to the use of blood and blood products as deemed necessary, both during and after
surgery for this hospitalization. The risks of exposure to AIDS, hepatitis or other infectious diseases
as well as the need for and available alternatives have been explained to me. (Cross through if this
does not apply)
I consent that any tissues, specimens, organs or limbs removed from my body in the course of any
procedure may be tested or retained for scientific or teaching purposes and then disposed of within
the discretion of the physician, facility or other health care provider.
I understand that the physician, medical personnel and other assistants will rely on statements about
the patient, the patient's medical history, and other information in determining whether to perform the
procedure or the course of treatment for the patient's condition and in recommending the procedure
which has been explained.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR
ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.
By signing this form, I acknowledge that the risks, benefits and alternatives to the above
procedure have been explained to me, that I have read or had this form read and/or explained
to me in general terms, that I fully understand its contents, that I have been given ample
opportunity to ask questions and that any questions have been answered satisfactorily. All
blanks or statements requiring completion were filled in and all statements I do not approve of
were stricken before I signed this form. I also have received additional information, including
but not limited to the materials listed below, related to the procedure described herein.
I hereby voluntarily request and consent for Dr. ______________________, as my physician, and
any other physician(s), and such associates, assistants or other medical personnel involved in
performing such procedure(s), to perform the procedure(s) described or referred to herein. I further
consent to the presence of device or supply manufacturer’s representatives in the operating room as
may be deemed appropriate by my physician.
Additional materials used, if any, during the informed consent process for this procedure include:
________________________________________________________________________________
Witnessed by:
____________________________________ ___________________________________
Responsible Physician
Person giving consent
Relationship to patient if not the patient:
___________________________________
Patient unable to sign because:
___________________________________
FORM 2-18096 REV. 10/2013
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