SAUDI GERMAN HOSPITAL - Madinah

PATIENTS NAME:

DATE/TIME:

PIN:

UNIT:

Consent for Cesarean Delivery

on Maternal Request

Consent for Cesarean Delivery
on Maternal Request
I, the undersigned:..............................................................

patient

relative

Relationship:......................................................................
(In case of Relative)
Hereby authorized the Hospitals permanent or visiting
physicians or their assistants to perform the following
procedure: Cesarean Delivery on Maternal Request
Refers to a primary cesarean delivery performed because the
mother requests this method of delivery in the absence of
conventional medical or obstetrical inductions for avoiding
vaginal birth.
Current Risks
Longer hospital stay/recovery
Increased maternal morbidity/mortality with higher
postpartum risk of :
o Cardiac arrest ( OR 5.1)
o Wound hematoma ( OR 5.1)
o Hysterectomy ( OR 3.2)
o Major puerperal infections ( OR 3.0)
o Anesthetic complications ( OR 2.3)
o Venous thromboembolism (OR 2.2)
o Hemorrhage requiring hysterectomy (OR 2.1)
Increased neonatal respiratory problems ( 6 folds )
Increased neonatal mortality ( OR 1.93)
Future Risks
Plaventa previa and accrete are significantly more
common in pregnancies following one or more
caesarean deliveries moreover, these complications
may necessitate cesarean hysterectomy.
If the patient undergoes a trial of labor in the future,
she will be at increased risk of uterine rupture.
Adhesions increase the difficulty of future
intraabdominal surgical procedures, and may increase
the risk of bowel injury.
For women planning several pregnancies, we
suggest avoiding CS on maternal request
Printed Name and Signature of Patient or Relative:
___________________________________________
ID / Iqama No: _____________________________
Date and Time:

WITNESS:
Name: _______________________________________
Signature: _________________________________
Date & Time:

Treating Doctor: _____________________________

Signature & Code: ___________________________
Form No. ******************

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