Circumcision consent form (Neonates)

Information about Infant (New-born) Plastibell Circumcision

 

What is Plastibell Circumcision?
This procedure involves using the Plastibell ring which is a plastic ring inserted
between the foreskin and the head of the penis. This causes the foreskin to fall off
naturally by blocking blood supply.

As this procedure uses a local anaesthetic, your child can only have this procedure up to the age of 8 weeks. After 8 weeks, your child will have to wait for the procedure until they are over the age of one, as they will need a general anaesthetic (which means they will be asleep during the procedure).   

The procedure takes place in a treatment room at Halimatu Musa Hospital
in by one of our experienced clinical staff.

Assessment
When you attend the clinic, a member of staff will ask you some questions and
examine your child. They are checking that there are no reasons that the
procedure cannot go ahead, and making sure that you understand what it will
involve.

Some babies are born with a condition called hypospadias which means that the
hole that your child passes urine from (meatus) is not in the right place. If your
child has this condition, we may have to check with the Urologist (a doctor who
specialises in the kidneys, bladder and genitals) that the circumcision can go
ahead. We will arrange this.

If your child is suitable for a circumcision, we will explain the procedure to you and
both parents/carer will have to sign the consent form. If one parent is unavailable then we would require their verbal consent.

The Procedure
We use the Plastibell(R) technique to perform the circumcision. The procedure
takes approximately 5-10 minutes.

Anaesthetic
Once consent has been given, we will apply a local anaesthetic cream around the base of your son’s penis this is to numb the penis. We will also give them pain medication (paracetamol). After about 30 minutes, we will inject a local anaesthetic at the base of the penis to numb it completely. This should not be painful. This will take full effect after about 10 minutes, after then the procedure can go ahead.

We will sometimes offer sucrose (sugar water) to your child during the procedure
as it will calm and settle your child, this is often used to help with pain relief in
small children.

The Plastibell
After applying a local anaesthetic, we place the plastibell between the head of the penis (glans) and the foreskin and use surgical string (ligature) to secure it.

We then remove any excess skin to prevent bleeding.

Over the next seven to ten days, the surgical string will work its way through the
layers of skin to completely remove them and will then fall off along with the
Plastibell into your child's nappy.

You will have to hold your child completely still during the procedure, and our staff
will be able to assist with this.

Risks
As with all medical procedures, circumcision carries some risks. The most common are bleeding and infection.

Bleeding from the wound happens in around 1 out of 100 procedures. Not all
children who experience a bleed will need a further procedure, but around 1 out of
2 will, and they usually need a general anaesthetic.

Infection happens less than 1 out of 100 procedures and we can easily treat this
with antibiotics. – You can reduce this risk by following the aftercare instructions.

 

Aftercare Instructions

• The procedure will take place in the morning. You will be able to go home
  shortly after the procedure takes place and your child has passed urine. A
  clinician will call you on the number you have provided, in the late afternoon
  of the same day to see how your son has settled.
• For the first 48 hours after the procedure, a member of staff may recommend that you give your child paracetamol.
• We may give you a numbing gel to apply to the head of the penis for the first
  48 hours if deemed necessary.
• Every time you change the nappy of your child, you may be asked by a member of staff to apply petroleum jelly (Vaseline) to the Plastibell and the head of the penis to make sure it doesn’t stick to the nappy.
• You may be asked by a member of staff to apply a barrier cream like Sudocream to the scrotum (the sac of skin that hangs from the body at the front of the pelvis, between the legs) to prevent rubbing or damage from the Plastibell.
• After 24-48 hours, you can give your child a bath. Your child should have a bath every day until the Plastibell falls off.
• There may be some swelling that appears around day five to seven after the
  procedure, this is normal.
• The ring of the Plastibell may start to partially separate at this point, that is
  normal and it should be allowed to do so on its own.
• After it falls off completely, the wound may look red, or have some white or
  yellow discharge, this should settle within two or three days.

 

Side Effects
It is normal to see a few small drops of blood, or a slight stain in your baby’s
nappy after this procedure. If, however, there is a lot of blood, or the small drops
do not stop after a few hours, then you should immediately attend to the Accident & Emergency Department at Halimatu Musa Hospital.

If there is a lot of redness around the skin edges or if there is any discharge, or if
you have any other concerns about a side effect of the procedure, then you
should speak to the hospital on 08114163781.

 

Statement of healthcare professional

• I am suitably trained and competent and have sufficient knowledge to consent this patient in line with the requirements of my regulatory body.
• I have discussed what the treatment is likely to involve, the benefits and risks of this procedure.
• I have discussed the benefits and risks of any available alternative procedures or treatments including no treatment.
• I have considered any additional patient-specific factors and discussed these with the patient alongside their particular concerns.
  
  

Statement of patient

Please read this form carefully. If you have any further questions, do ask –
we are here to help you. You have the right to change your mind at any time,
including after you have signed this form.

You must consent to the following section to proceed with your surgery:

• I confirm that I have read and understood the consent form.
• I understand the diagnosis and agree with the course of treatment described
  on this form for my child.
• I have had the opportunity to discuss treatment alternatives, including no treatment.
• I have had the purpose, aims and possible risks of treatment explained to me.
• I understand that the operating person, who will have appropriate expertise
  to carry out the procedure, may not have been involved in my pre-operative
  assessment or care to date.
• I understand my anaesthetic options will be or have been discussed with an
  anaesthetist where we will jointly decide which option is best for my child. I understand that the type of anaesthesia may need to be altered if there are any complications during the procedure.
• I have been told about additional procedures which are necessary prior
  to treatment or may become necessary during my child's treatment. This may include permanent skin marks, photographs, and/ or tissue samples to help with treatment planning and identification.
• I understand that any procedure in addition to those described on this form
  will only be carried out if it is necessary to save my child's life or to prevent serious harm to m health. I have spoken to my health care professional about any life saving procedures I do not wish to happen.
• I understand that relevant and appropriate patient specific data for this procedure will be collected and may be used in the context of providing clinical care, and/or audit purposes in compliance with Data Protection Act (2023).