CESAREAN SECTION
INFORMED CONSENT
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PATIENT NAME: __________________________ DATE: ________________TIME: ___________
The diagnosis requiring this procedure is pregnancy with contraindications to a vaginal delivery.
The nature of the procedure is: The delivery of the infant through an abdominal incision.
The purpose of this procedure is: To deliver the baby and reduce the possible increased risks to the mother or infant,
which might result from a vaginal delivery.
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:
 Damage to your bladder, bowel, uterus, tubes, ovaries and/or major blood vessels requiring repair or removal or
partial removal of a portion of that organ.
 Possible sterility
 Possible fistula formation (an opening between bowel, bladder, ureter, vagina and/or skin) caused by an injury to
the bowel, bladder or ureter.
 Possible injury or death to the baby
 Possible formation of blood clots or emboli that may travel to other parts of the body and cause stroke or death
 Possible rupture of the uterus that might require a hysterectomy (removal of the uterus, fallopian tubes and /or
ovaries)
 Possible necessity of cesarean section for future pregnancy
 Possible need for other additional surgery.
The likelihood of success of this procedure is:
□ good □ fair
□ poor
THE PRACTICAL ALTERNATIVE TO THIS PROCEDURE IS attempted vaginal delivery.
If I choose not to have the above procedure, my prognosis (future medical condition) is possible increased risks to
the mother and/or infant.
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.
I consent to the use of conscious or deep sedation as planned by my treating physician. The risks, benefits and
alternatives of such sedation 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 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.
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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:
__________________________________________________________________________________
____________________________________
Signature of Person giving consent
___________________________________
Relationship to patient if not the patient
Patient unable to sign because:
___________________________________
Responsible Practitioner’s Statement:
I have reviewed that contents of this form, including the risks, benefits and alternatives to the proposed procedure,
with the patient or the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to
ask questions.
____________________________________
Responsible Practitioner
___________________________________
Date/Time
CONSENT UPDATE
I acknowledge an understanding of the above discussion and explanations. I have been given the opportunity to ask
questions and discuss that procedure during the update process. I request and consent to the performance of the
procedure described or referred to above.
_____________________________
Signature of Person giving consent
_______________________________
Relationship to patient if not the patient
Patient unable to sign because:
___________________________________
_____________________________
Witness
Seq# 18099
Revised: 1/05
____________________
Date/Time