Here you go... I had it translated into spanish if you are interested..
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_________
1. I understand that I have had one or more prior cesarean[s].
2. I understand that I have the option of undergoing an elective repeat
cesarean or
attempting a vaginal birth after a cesarean [VBAC].
3. I understand that approximately 70% of women who undergo a VBAC will
successfully deliver vaginally.
4. I understand that the risk of a uterine rupture during a VBAC in someone
such as myself, who has had a prior incision in the noncontracting part of
my uterus, is around 1%.
5. I understand that VBAC is associated with a higher risk of harm to my
baby than to me.
6. I understand that if my uterus ruptures during my VBAC, there may not be
sufficient
time to operate and to prevent the death of or permanent brain injury
to my baby.
7. I understand that the decision to have a VBAC is entirely my own, and
the option of an
elective repeat cesarean has been discussed with me.
8. I understand that VBAC carries a lower risk to me than does a cesarean
delivery.
9. I understand that if I deliver vaginally, I most likely will have fewer
problems after delivery
and a shorter hospital stay than if I have a cesarean delivery.
10. I understand that during my VBAC, the use of oxytocin(Pitocin) hormone
to make my
uterus contract may be necessary to assist me in my vaginal delivery,
and the risks of this
drug have been thoroughly explained to me.
11. I understand that if I choose a VBAC and end up having a cesarean
during labor, I have a
greater risk of problems that if I had had an elective repeat
cesarean.
12. I have read or have had read to the above information and I understand
it.
I have received all the information I want. After discussing the matter
with my doctor,
I want to attempt a VBAC. I want a repeat cesarean.
____________________ X____________________
[PRINT PATIENT'S NAME] [PATIENT'S SIGNATURE]
____________________ X____________________
Geffrey H. Klein, MD
listowner: OB-GYN-L
Advisory Board Chairman, OBGYN.net < http://www.obgyn.net >
Co-moderator: sci.med.obgyn
gklein@bcm.tmc.edu gklein@icsi.net
http://members.aol.com/gklein01/geff.html
6800 W. Loop South #520
Bellaire, Texas 77401
(713) 664 8900
