Request & Consent for Medical Termination of Pregnancy

Please read this form carefully before you have your consultation with the doctor.
You should tick or mark the box next to each paragraph to indicate that you have read and understood that section.
You will have the opportunity to discuss any specific questions or concerns that you may have when you talk with the doctor.
Please do not sign this consent form until you have spoken with the doctor.

Name*

First NameLast Name

Patient Number*

Date of Birth*

Date

Medical termination of pregnancy is now considered a safe option for the termination of pregnancy from 5 to 9 weeks, however, no medical practitioner can provide a guarantee or assurance regarding the outcome of any medical treatment, and this clinic has an obligation to warn you of the known risks when undergoing a medical termination of pregnancy, regardless of how unlikely these risks are. It is possible to experience a complication of a severity which could lead to infertility or in very rare cases could even be fatal although complications of this severity are extremely rare.

 Description of the medical abortion procedure:

The doctor will use an ultrasound to verify that the pregnancy is in your uterus and is between 5 to 9 weeks. While at the hospital, you will be given an oral medication (mifepristone) which prevents the pregnancy from developing.

You will be provided with another type of medication (misoprostol) which must be taken 36 to 48 hours later at home where you must have support from another responsible person and be within 1 hour from a hospital. This second medication causes your uterus to contract and expel the pregnancy tissue. This part of the process may be painful and the bleeding may be heavy and prolonged but is usually able to be relieved with oral pain relief. You must agree to return to the clinic for follow-up in 14 days where we will perform an ultrasound scan to verify that the pregnancy has been terminated. In some cases, additional follow-up visits and tests may be required.

Alternatives to medical abortion include:

 Surgical abortion:

Can be performed between 5 – 15 weeks and usually only involves a single visit lasting about 3 hours. The pregnancy is verified with an ultrasound scan and you will then be given IV sedation which make you sleepy and will provide strong pain relief. Your cervical canal is opened gently to about 6-8 mm diameter through which a sterile plastic suction tube is passed into your uterus and the pregnancy tissue is removed with gental suction. A final ultrasound scan is performed to check that the procedure was successful and to minimise the risk of having tissue remaining.

 Late medical termination of pregnancy 14-23 (+6 weeks) weeks:

The termination (abortion) is induced by inserting four pills into your vagina, followed by tablets that you put under your tongue. This will cause your womb to contract (rather like labour) until the neck of the womb opens and the pregnancy is expelled (like a miscarriage). At first you will get crampy, period-like pains but they will get stronger near the time that you abort. You will be offered painkillers if you need them. If you are more than 22 weeks pregnant, we will arrange an extra scan to allow the fetus to be given an injection so that it is not alive during the abortion process. To reduce the risk of infection, when you have your first dose of misoprostol the nurse will give you an antibiotic suppository (metronidazole) into your back passage. You will also be given four oral antibiotic tablets (azithromycin).

An uncomplicated abortion should have no effect on future fertility.There is a small risk that you might have difficulty becoming pregnant if you have a serious complication like perforation of uterus or an untreated infection.

If the placenta does not deliver or if you bleed excessively, you may need to have a surgical procedure under general anaesthetic. If you have any questions, please ask the nurse looking after you.

Known possible complications of the proposed medical abortion process:

 Retained pregnancy tissue. This is where small pieces of pregnancy tissue remain in the womb. This may cause cramping pain, prolonged or heavy bleeding, or infection. This occurs in about 1 in 20 medical abortions and may require a surgical procedure to clear the tissue that was left behind.

 Clot retention. A blood clot builds up in the womb. This can cause cramping pain, and a surgical procedure may be required to remove the blood clot from the womb.

 Infection. An infection following a termination of pregnancy is uncommon (about 1 in 200 however, it is important that any suspected infection is treated immediately. You should always call the clinic or consult your doctor if you experience any signs of infection such as prolonged fever or unusual vaginal disharge.

 Haemmorhage. Heavy bleeding (over 300mls of blood loss) during the medical abortion occurs in about 1 in 500 patients and is usually caused by retained pregnancy tissue. This usually required a surgical procedure to remove any remaining tissue, and in some cases, transfer to a hospital and a blood transfusion may be needed.

 Failed termination procedure. In about 1 in 500 termination procedures, the pregnancy is not removed and continues inside the womb. If there is any doubt about the result of the medical abortion procedure, we will ask you to have additional blood tests to monitor your hormone levels and confirm that the pregnancy has ended. You should call the hospital immediately if pregnancy symptoms continue or if a urine pregnancy test shows a positive result at more than three weeks after the procedure.

 Adverse reactions to medicines. The medications used to perform the abortion process have been in use for many years and are known to be safe for most women. However severe allergic reactions are sometimes possible and must be treated immediately in hospital.

 Depression or mood problems. The majority of women do not find an abortion to be emotionally or psychologically harmful, although some women find it stressful or difficult in the short-term. Most women cope well and do not experience long-term problems. However, depression or mood problems can sometimes occur in situations where emotional support is lacking, when the woman was not completely clear about her decision, when she was feeling pressured into choosing a termination or when there has been a previous history of depression or mental health problems. If you suspect that you are at risk in relation to this issue, you should mention it to the doctor so that a referral for further counselling can be arranged.

 Additional unexpected costs: It is sometimes necessary to arrange for additional diagnostic tests or for treatment at another facility by another medical practitioner, in circumstances that were not foreseeable or not known to be needed at the time this consent was given. You will be advised if any such tests or referrals are necessary, but you will be responsible for any costs that may arise if this happens.

 The medications used to terminate an early pregnancy can be very dangerous if taken without supervision from a doctor who is trained and experienced in this field. I understand that I must not give these tablets to anyone else and I will safely dispose of any tablets which may be left over after the medical abortion is completed.

 I understand that a surgical abortion may be required if the bleeding is prolonged and/or extremely heavy, or if pregnancy tissue remains, The medications are know to cause birth defects so in the event of a continuing pregnancy, a surgical termiation will be required.

Do you have any specific concerns?*

By signing this consent form:*

I am requesting and consenting to a medical termination of pregnancy being performed, along with the administration of drugs and other medications normally associated with this procedure.I am acknowledging that I have read and understood this consent form.I am sure of my decision to terminate the pregnancy.I have had the opportunity to ask the doctor questions, and I am satisfied with the answers to these questions. I acknowledge that all care will be taken to provide an uncomplicated outcome from my procedure, but that no guarantees or assurances have been made to me concerning the results of this treatment.I accept all risks, whether stated or unstated, and I understand that complications can occur with any medicaltreatment or procedure.I understand that it is impossible to list every possible adverse outcome or complication that could occur andthat the treatment may not always be successful.In the event that additional diagnostic tests are required, or additional treatment is required at an external facility, I consent to the release of any relevant medical reports or test results to the Hospital.I understand that the abortion process is not complete until I have attended a follow-up appointment in 10 – 14 days. I agree to return to the Hospital for the scheduled follow-up appointment and I understand that these appointments are limited in availability and rescheduling to a date of my choosing may not always be possible.

Name*

First NameLast Name

Signature*

Date*

Date

Rationale for initiating Termination of Pregnancy (TOP)*

Risks & Contraindications*

Benefits & Advantages*

Suggested viable/better alternative(s) proposed by Pharmacist/MO/Consultant (If applicable)*

 I have consulted with the patient, explained the procedure and answered any of her questions. I believe that she has understood the nature and purpose of the operation and wishes to proceed.

 It is my opinion that the risk to this woman’s physical and/or mental health from a continuing pregnancy is greater than the risk of terminating the pregnancy.

Consultant/Medical Officer*

First NameLast Name

Signature*

Date*

Date