Lyndon D Taylor MD LLC

The Excellent Care You Need,  The Compassion You Deserve

VBAC - Patient Consent Form

IMPORTANT: YOU MUST PRINT THIS PAGE

As you may know, there are risks in any medical, surgical procedure or treatment. Just being pregnant carries some risk as there are risks in everyday activities, such as driving. The following checklist is designed to help you make an informed decision as to your attempt to deliver “normally” after you had a prior cesarean section. This procedure medically is called a Vaginal Birth After Cesarean section, and is abbreviated “VBAC”. Your other option is to have a repeat cesarean section.  Please read and initial each statement below to acknowledge you read it, understood it, and accept it. Then, choose your option of attempting a VBAC or a repeat cesarean section to deliver your baby.

Lyndon D. Taylor, MD

1100 Lake Street, Suite 260

Oak Park, Illinois 60301

To contact us:

Phone: 708-848-9440

Fax: 708-848-4415

Email: lyndontaylor@msn.com

Website: http://www.LyndonTaylorObGyn.yourMD.com

LYNDON TAYLOR

OB/GYN

If you agree to all the statements above, select the type of procedure you want, then sign your name on the line above, date your signature, and print your name and birthdate where indicated.

Accurate and complete medical history is essential to proper medical care. We need the records from your prior cesarean section(s) in order to be able to care for you.

Click here to print a Patient Medical Records Release Authorization Form.

Fill it out completely, sign it, and mail it to each hospital where you had a prior cesarean section.

Fax or mail all forms to

Dr. Lyndon Taylor

1100 Lake Street, Suite 260

Oak Park, Illinois 60301

Fax (708) 848-4415

SIGN YOUR NAME ABOVE.

I understand that I have had one or more prior cesarean sections.

I understand that I have the option of an elective repeat cesarean section or an attempt at a vaginal birth after cesarean (VBAC).

I understand that between 60% and 80% of women who attempt a VBAC will successfully deliver vaginally.

I understand that VBAC carries a lower risk to me than a cesarean delivery, and that the benefits of a successful VBAC include decreased blood loss, decreased post-delivery complications, and a shorter recuperative period.

I understand that the risk of a uterine rupture during VBAC to someone like me who has had a prior incision in the non-contracting part of my uterus is at least 1%.

I understand that VBAC is associated with a higher risk of harm to my baby than to me.

If my uterus ruptures during my VBAC, I understand that there may not be sufficient time to operate and prevent death or permanent brain injury to my baby.

I understand that the exact frequency of death or permanent neurologic injury to the baby when the uterus ruptures has been reported to be as high as 50%.

I understand that the risks to me after rupture of the uterus include, but are not limited to, hysterectomy (loss of the uterus), blood transfusion, infection, injury to internal organs (bowel, bladder, ureter), blood coagulation problems, and/or death.

I understand that probable contraindications to VBAC include previous classical uterine incision, multiple gestations (twins, triplets, etc.), and breech presentation.

I understand that during my VBAC, the use of oxytocin (Pitocin), a hormone to make my uterus contract, may be necessary to assist me in my vaginal delivery, and that there may be increased risks with the use of oxytocin during VBAC.

I understand that if I choose a VBAC and end up having a cesarean section during labor, I have a greater risk of problems than if I had an elective repeat cesarean in the first place.

I understand that if I have a planned repeat cesarean delivery, that I have an increased risk of hysterectomy, blood clots, adhesions, chronic pain, bowel problems, and/or problems with subsequent cesareans, such as placenta previa and placenta accreta.

I want to attempt a VBAC.

I want  a repeat cesarean.

I have read or have had read to me the above information and I understand it.

PRINT TODAY’S DATE

PRINT YOUR NAME ABOVE.

PRINT YOUR DATE OF BIRTH

Chicago VBAC

 

What’s best

for you?