SOUTH AVENUE WOMEN’S SERVICES
ROCHESTER, NY 14620
(585) 271-3850

CONSENT FOR SURGICAL ABORTION

INSTRUCTIONS: Place your initials after each set of statements to indicate that you read and understand them and have had all your questions answered. PLEASE INITIAL ALL STATEMENTS

GENERAL INFORMATION

Before you give your consent, be sure you understand the information we are providing. Remember your request for an abortion is entirely voluntary. You may ask for a copy of this form.

I understand that my three options regarding the pregnancy are parenthood, adoption and abortion.

In the rare circumstance that I need emergency medical care at a level not provided by the South Avenue Women’s Services, I understand that the financial responsibility is mine or that of my health insurance.

PROCEDURE

On the day of the procedure, drink only a small amount of clear fluids and take Ibuprofen 800mg one hour before the procedure. The suction abortion consists of the following steps: a vaginal exam and/or a vaginal probe ultrasound, placement of a metal speculum into the vagina, cervical cleansing with soap, and injection of numbing medicine around the cervix. The cervix will then be stretched using graduated dilators as needed, and then a small plastic tube will be inserted into the uterus. This tube will be connected to suction generated by a machine to remove the pregnancy. The whole procedure only takes a few minutes. There is usually some cramping during the procedure, but this will usually subside within 5 – 10 minutes.

I understand that early abortion is considered one of the safest surgical procedures. The risks of abortion are less than those of childbirth. The risks include:

1 in 100 chance that an infection of the uterus will develop after the abortion. While this problem is treated with antibiotics, there is a small chance that a repeat aspiration (dilation and curettage) or hospitalization may be necessary.

1 in 100 chance that tissue will be left inside of the uterus, leading to an “incomplete” abortion. This problem may lead to excessive bleeding, infection or both. If this complication occurs, it may require a repeat aspiration in our office or the emergency room.

1 in 500 chance that the uterus will be perforated (an instrument going through the wall of the uterus that could damage internal organs such as intestines, bladder or blood vessels). Treatment may consist of observation, laparoscopy or abdominal surgery. The likelihood of hysterectomy (removal of the uterus) in this setting is less than 1 per 10,000 abortions.

Allergic reaction due to an allergy to the local anesthetic is possible. It is important that you use only medically necessary drugs and avoid alcohol and other nonprescription drugs on the day of the abortion.

1 in 1000 chance that excessive bleeding will require a blood transfusion. Lesser amounts of bleeding may require a repeat aspiration.

1 in 200 chance that the cervix will tear which may require treatment with stitches in the cervix.

1 in 500 chance that the procedure will fail to end the pregnancy. This may be due to a divided uterus, very early pregnancy, or other causes. Another aspiration procedure is recommended when this happens. A tubal (ectopic) pregnancy is not ended by an abortion and may require an abdominal operation to remove it. This is not covered by our abortion fee. Follow up is important.

There is a rare chance that a severe emotional reaction may occur, which is usually of short duration. Most women report a sense of relief, although some experience depression or guilt. Serious psychiatric disturbance after an abortion appears to be less frequent than after childbirth, but should be evaluated by a competent health care provider.

Future pregnancies are statistically not known to be affected by an uncomplicated early abortion.

1 in 10,000 chance of death, which is most often associated with general anesthesia or termination of a more advanced pregnancy (neither of which we offer). The risk of death during childbirth is 7 times greater.

1 am now aware of possible serious problems that may occur and how to get medical help quickly at the emergency room at Highland Hospital or will call (585) 271-3850 if any of these develop. I have read the above information and have had all my questions answered.

We do offer a form of conscious sedation utilizing Demerol and Valium at a cost of $30.00. This is not covered by any health insurance plan. If you think you want this form of analgesia, please let the office staff know and we will provide you with the information and have you sign a consent form.

I authorized South Avenue Women’s Services to dispose of any tissues or organs removed as a result of the procedure.

I have read the above information about the surgical abortion procedure and the risks involved which include, but are not limited to those stated in these paragraphs. I understand this information and have had all my questions answered and I request to undergo the surgical abortion procedure.

Signature of patient:

Date:

Witness (option):

Date:

I witness the fact that the patient received the above mentioned information and said she understood it as well as all her questions were answered.

Signature of South Avenue Women’s Services Health Care Professional:

Date: