Looking for something? Start here.
Custom Search

 

Want The Unnecesarean in your inbox? Enter your email address:




 

   

« Canadian Government Publishes Birth Intervention Rates for 2008-2009 | Monday Open Thread »
Wednesday
May192010

VBAC Consent Form Revision Revisited: Your Feedback Requested Again

Bookmark and Share

Share 

 

“Ob” printed out all of your suggestions for revisions to his malpractice carrier mandated VBAC permit that his malpractice carrier requires and took them into consideration.

 

His caveats and responses to a few suggestions: 

  • He has separate forms for elective and elective repeat cesareans and cannot combine them or give them side-by-side.  He consults first when he and the patient get to the forms. 
  • Patients always have the right to vacillate.
  • The elective repeat cesarean form is worded in favor of VBAC.
  • He has to give nonspecific numbers for legal purposes, noting that “somewhere someone has a different number and it can be used against one,” so it’s either nonspecific or no option. 
  • He performs scar checks (revisit or revision) gently after delivery (in all his years has only found one silent separation but she hemorrhaged and required a mini laparotomy repair.)
  • Epidurals do not seem to mask dehiscence pain.  They are not contraindicated. 
  • There is no such thing as impending rupture.  It has or it hasn’t. 
  • He cannot put incorrect info in here and must consult with all patients at their first visit, which is when this is given to the patient.  She MUST take it home to read and bring it back at the second visit.

 

Please read the previous version and kindly share your thoughts if you have a moment.

 

 

Consent for Vaginal Birth After Cesarean Section (VBAC)

 

Name of Patient: ________________________       Chart # _____________

 

Please initial each line:

 

_____ 1.  I understand that I have had one or more previous cesarean section(s). My records have been reviewed from my delivery (ies) and per recommendations of the American College of Obstetrics and Gynecology I am being offered a trial of labor.

 

_____ 2.  I understand that I have the option of undergoing an elective repeat cesarean section or attempting a vaginal birth after a cesarean (VBAC).

 

_____ 3.  I understand that approximately 70% of women who choose a VBAC will successfully deliver vaginally.

 

_____ 4.  I understand that VBAC is associated with a higher risk of harm to my baby than to me if there is a complication of labor.

 

_____ 5.  I understand that VBAC carries a lower risk to me than does a cesarean delivery if there is no complication of labor.

 

_____ 6.  I understand that if I deliver vaginally, I most likely will have fewer problems after delivery and a shorter hospital stay than if I have a cesarean delivery.

 

_____ 7.  I understand that during a VBAC the use of oxytocin (Pitocin) hormone that can assist with uterine contractions is relatively contraindicated.  If it appears this medication is indicated we will discuss its usage and options before deciding to proceed.  A Pitocin induction is contraindicated in VBAC’s and this drug will not be used in this manner.

 

_____ 8.  I understand that the decision to have a VBAC is entirely my own, and the option of an elective repeat cesarean has been discussed with me along with the option of a repeat cesarean section and the risks and benefits of each. 

 

_____ 9.  I understand that if I choose a VBAC and after laboring require a repeat cesarean, I have a greater risk of infection than if I had had an elective repeat cesarean however there is a theoretical decrease risk for transient breathing difficulty to your newborn.

 

_____ 10.  I understand that the risk of a uterine rupture (acute separation of the uterine wall where the previous cesarean delivery was performed) during a VBAC in someone such as myself, whose prior incision was in the noncontracting part of my uterus (a low transverse incision), is around 1%.  Most uterine ruptures are not catastrophic (resulting is fetal or maternal harm) but this is unpredictable.

 

_____ 11.  I understand that if my uterus ruptures during my VBAC, there may not be sufficient time to operate and to prevent the death of or permanent brain injury to my baby or myself but this is an uncommon event.

 

_____ 12.  I understand that if my uterus ruptures during my VBAC, a hysterectomy (removal of the uterus) may become necessary at a higher rate than with a scheduled cesarean or a vaginal delivery.

 

_____ 13.  I understand that [“Ob”] cannot guarantee that other physicians who may be covering for him will allow me to attempt a VBAC (while one cannot be forced to undergo a repeat cesarean delivery you are placing yourself at odds with what I require of you to be able to offer this option of delivery.  I cover for myself most of the time but I must have the support of other physicians to maintain my practice.  As labor is unpredictable I cannot guarantee that I will be available at all times.)

 

______14.  I understand the complications of VBAC may include but are not limited to uterine rupture and may also include any complication of a non-VBAC vaginal delivery.

 

I understand the above information.  I have been given an opportunity to ask questions and have had them answered to my satisfaction. 

 

______I desire to attempt a VBAC.       ______ I desire a repeat cesarean section.

 

 

____________________________                    _____________________

Patient’s signature                                               Date

 

____________________________

Physician’s signature

 

 

   

PrintView Printer Friendly Version

EmailEmail Article to Friend

Reader Comments (20)

Can #3 include that the other 30% have C-sections? e.g.

3. I understand that approximately 70% of women who choose a VBAC will successfully deliver vaginally, and approximately 30% will end up with a repeat C-section.

I know this seems obvious, but there is nothing wrong with obvious. When you see "70% success," you think "30% failure!" and it's helpful to remind women that in this case, "failure" is "another C-section," not something truly abhorrent and rare like maternal or fetal demise.

Also, someone once posted in a comment the observation that this ratio is actually similar to the overall C-section rate. I know they are different populations and it's not a very scientifically interesting observation, but I think it could be a real confidence boost for women who are unsure about VBACs.

May 19, 2010 | Unregistered CommenterJMT

I would change #9 so it matches the rest of the statements (changes in ALLCAPS)-- I understand that if I choose a VBAC and after laboring require a repeat cesarean, I have a greater risk of infection than if I had had an elective repeat cesarean however there is a theoretical decreaseD risk for transient breathing difficulty to MY newborn.

May 19, 2010 | Unregistered CommenterMichelle

I agree with JMT's comment- making it clear that the other 30% have babies, just not vaginally, might be more reassuring to the reader.

Otherwise, it seems very clear and informative, and evidence-based. I like it!

May 19, 2010 | Unregistered Commentersara

I like it. It is clear. It makes no promises of success. It makes no promises of failure. And best of all, it won't make a woman feel that her uterus is a ticking time bomb.

May 19, 2010 | Unregistered CommenterJoy Szabo

This definitely sounds better and more positive to me :-) ... My only comment is that #8 might have a typo? it discusses the option of ERCS twice?

May 19, 2010 | Unregistered CommenterJennifer

#4 and #5 make an attempted VBAC sound selfish. Could these be perhaps combined and re-worded?? After all, a c-section is hardly risk-free for the baby either.

May 19, 2010 | Unregistered CommenterIsabel

I like it, a lot. I think it's honest about the risks of VBAC without being hysterical, and doesn't give the impression that an elective repeat c-section would be risk free and an obviously better choice. That's what you want from a consent form. I honestly would not change the parts about VBAC posing a greater risk to the baby than the mom, and c-section posing greater risk to the mom than VBAC, because those are the facts, and moms need facts to make informed choices. We're not emotionally crippled children who need the truth softened up to help us make the "right" decision; we just need true, unbiased information. I also think that #3 is perfectly clear in stating that 70% of women attempting VBACs successfully deliver vaginally. That "deliver vaginally" part gives the necessary context for "successfully," and I don't think it leaves room for someone to mistakenly assume that the other 30% lose their babies. Not to mention that the form also states that the likelihood of rupture is only around 1%, and that most ruptures are not catastrophic.

I would reword #13. You appear to be saying that you cannot guarantee that other physicians covering for you will allow a VBAC, and that while mom cannot be forced to have a c-section, fighting for the right to VBAC while in labor is not an ideal situation. I totally agree with that, but your wording is somewhat confusing. I had to re-read several times, and I'm still not entirely sure what you mean by "you are placing yourself at odds with what I require of you to be able to offer this option of delivery."

Other than that, you have some typos and grammatical mistakes:

In #8 you say that you and mom have discussed both "elective repeat cesarean" and "repeat cesarean section" -- I'm guessing that was supposed to be that you've discussed both c-section and VBAC?

In #9 you need a comma after the word "VBAC" (commas are tricky, and I would actually add a whole bunch of them to this form, but this one is important because it sets off an independent clause), a semicolon between "cesarean" and "however," to change "decrease" to the past tense, and to change "your newborn" to the first person "my newborn."

In #10, change "resulting is" to "resulting in."

In #11, set off the clause "or permanent brain injury to" with commas before and after, and add a comma after "myself."

In #14, set off the clause "but are not limited to" with commas before and after.

These are just a few minor mistakes, but correcting them will improve the readability of the document. Regardless, I think the overall tone and wording of your form is excellent, and recommends you as a knowledgeable, supportive doctor.

May 19, 2010 | Unregistered CommenterMichelle Potter

"_____ 9. I understand that if I choose a VBAC and after <<>>laboring require a repeat cesarean, I have a greater risk of infection than if I had had an elective repeat cesarean however there is a theoretical decrease risk for transient breathing difficulty to your newborn."

This is written in a very confusing way. I would suggest language like "some studies have shown that a cesarean performed during labor leads to less breathing difficulties in your newborn and less risk of your newborn being admitted to the neonatal unit than after a planned repeat cesarean. "

There is nothing theoretical about theincreased risk of transient tachypnea of the newborn or more severe RDS, requiring NICU admission and/or observation after planned cesarean without labor.

http://www.ncbi.nlm.nih.gov/pubmed/18378740

I love it. I think it is clear and positive, but doesn't guarantee success. It also gives the woman a good place to start with her own research. I may just print one off for my own medical records so it'll get transferred wherever I choose to deliver next (my hospital bans them).

May 19, 2010 | Unregistered CommenterHeather

I love it!!! What a great improvement over the initial version. As an anthropologist, I ask participants to sign informed consent all the time, and one of the things that I find far outweighs the actual consent form is the time that the practitioner/researcher takes to address concerns and answer questions.
Sending the consent form home and having the patient take the time to read it and jot down any questions or musings that they may have allows for a much more INFORMED consent when they can sit down and have the OB actually address questions and make clarifications if needed. Ultimately, the actual consent form is really only half of the process of attaining truly informed consent.

May 19, 2010 | Unregistered CommenterAlissa
Comments for this entry have been disabled. Additional comments may not be added to this entry at this time.