CONSENT FORM Medical Termination of Pregnancy

PROPOSED PROCEDURE: Medical Termination of Pregnancy – Ending pregnancy with the use of tablets by mouth and into the vagina at LESS THAN 9 WEEKS (<63 days). THE INTENDED BENEFITS: To end the Pregnancy CONTRACEPTION: __________________ to start _____________________ ANTI – D: If the blood test shows that your blood type is Rhesus Negative, an Anti-D injection will be given. SIGNIFICANT, UNAVOIDABLE, FREQUENTLY OCCURING RISKS: Bleeding – is variable between 3 days and 3 weeks. It may be heavy with clots initially, but should then become lighter. Infection – common. Antibiotics to try and prevent infection will be given, but it may still occur in 1% women. Incomplete emptying of the womb - In 5% women not all the pregnancy tissue comes away and further treatment may be necessary. The pregnancy continues in < 1 in 100 (<1%) cases. RARE SITUATIONS: Where there is sudden haemorrhage an initial injection is given to contract the womb. If this is unsuccessful then occasionally it is necessary to empty the uterus of the remaining tissue in the operating theatre. This is called Surgical Management of Miscarriage or Evacuation of Retained Products of Conception (ERPC). This involves a general anaesthetic. Blood transfusion may be necessary in 1/1000 cases (0.1%) The leaflet “Termination of Pregnancy” has been provided. SENSITIVE DISPOSAL: The products of conception will be disposed of by sensitive cremation. If you disagree with this please say, as there are other options available. STATEMENT OF HEALTHCARE PROFESSIONAL: I have explained the above to the patient. I have explained what the treatment will involve, the benefits and risks of this and any alternative treatments (including no treatment) and discussed any particular concerns of this patient. SIGNATURE: JOB TITLE: NAME: DATE:

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CONSENT FORM Surgical Termination of Pregnancy

PROPOSED PROCEDURE: Surgical Termination of Pregnancy – inserting instruments through the neck of the womb into the womb to remove the pregnancy by suction. CONTRACEPTION: To provide ongoing contraception, in addition, to insert: - an intra-uterine Copper contraceptive device - an intra-uterine hormone containing contraceptive device (Mirena coil) - a Nexplanon contraceptive implant into the RIGHT/LEFT inner upper arm - a Depoprovera intramuscular contraceptive injection - none of the above, preferred contraception is: ________________________ THE INTENDED BENEFIT: To end the Pregnancy ANTI – D: If the blood test shows that your blood type is Rhesus Negative, an Anti-D injection will be given. SIGNIFICANT, UNAVOIDABLE, FREQUENTLY OCCURING RISKS: Bleeding – is variable between 3 days and 2 weeks. It should become lighter with time. Occasionally there may be haemorrhage Pain – there will be some pain like period pain Infection - Antibiotics to try and prevent infection will be given, but it occurs in 1% women. Incomplete emptying of the womb - In 1% women not all the pregnancy comes away and further treatment may be necessary. The pregnancy continues in <1 in 100 (<1%) cases. RARE SITUATIONS: Anaesthetic risk: all general anaesthetics carry a small risk Haemorrhage: Medications are given to contract the womb. Occasionally a balloon may be needed inside the womb to exert pressure to stop bleeding. Blood transfusion may be necessary in 1/1000 cases Damage to the cervix 1 in 100 (1%) Ascherman’s Syndrome (internal scarring of the womb) Perforation of the uterus – 1-4/1000 (0.1%), Damage to surrounding structures Need for additional procedures – Laparoscopy to investigate damage +/- Laparotomy to repair The leaflet “Termination of Pregnancy” has been provided. SENSITIVE DISPOSAL: The products of conception will be disposed of by sensitive cremation. If you disagree with this please say, as there are other options available. STATEMENT OF HEALTHCARE PROFESSIONAL: I have explained the above to the patient. I have explained what the treatment will involve, the benefits and risks of this and any alternative treatments (including no treatment) and discussed any particular concerns of this patient. SIGNATURE: JOB TITLE: NAME: DATE:

ALL PATIENTS STATEMENT OF INTERPRETER: I have interpreted the above information to the best of my ability and in a way that I believe the patient can understand. SIGNATURE: NAME: DATE: STATEMENT OF PATIENT: I agree to the course of treatment described above on this form. I understand that I will be looked after by appropriately trained and experienced NHS staff, but that there is no guarantee that any one particular person will deliver my care. I understand that any additional procedures or treatments that are not described on this form will only be carried out if necessary to save my life or prevent serious harm to my health. I have been told about the common and serious risks and complications of this treatment. I have been told about additional procedures that might be necessary. I have listed below any procedures that I DO NOT want to be carried out without further consultation. SIGNATURE: NAME: DATE: A witness / advocate should sign here if the patient is unable to sign, but has indicated their consent. A person with parental responsibility should sign here in addition, for young persons under the age of 16. A young person aged 16-18 may also ask a person with parental responsibility to sign here. SIGNATURE: NAME: DATE: DESIGNATION: CONFIRMATION OF CONSENT: To be completed by a health professional, when the patient has been admitted for the procedure, and when this form has been signed by the patient in advance. On behalf of the team treating the patient I have confirmed that she / he has no further questions and wishes the treatment to go ahead. SIGNATURE: NAME: DATE: DESIGNATION: