A. Does the patient have capacity? Yes   GO TO section B  No   COMPLETE section A

i. a) Is the patient aged under 18 years? Yes (document parent/guardian name below) No   GO TO iiYou must adhere to the Advance Health Directive (AHD) or the consent obtained from a substitute decision-maker.ii. a) Does the patient have an AHD that is applicable to the

procedure, treatment or investigation? Yes   No   GO TO iii

b) If yes, has the AHD been sighted and a copy is in the medical record? Yes   No   GO TO iii

iii. Substitute decision-maker (select one only): Attorney(s) for health matters under an Enduring Power of Attorney or AHD Tribunal-appointed guardian Statutory Health Attorney If none of these, the Office of the Public Guardian must provide consent (ph: 1300 653 187)

Name of substitute decision-maker(s) or parent/guardian:

Signature of substitute decision-maker(s) or parent/guardian:

Relationship to the patient (e.g. substitute decision-maker or parent/guardian)

Date: Phone number:

B. Does the patient need Interpreter/

cultural services?i. a) Is a language interpretation service required? Yes   No   GO TO ii

b) If yes, is a qualified Interpreter present? Yes (complete section K)   No   N/Aii. a) Is a cultural support person required? Yes   No   GO TO section C

b) If yes, is a cultural support person present? Yes   No   N/A

C. Condition and treatmentThe doctor/clinician has explained that I have the following condition (doctor/clinician to document in patient’s words):

This condition requires a procedure (doctor/clinician to document, include site and/or side where relevant to the procedure):

The following treatment will be performed:Caesarean section is an operation performed to deliver the baby from the uterus. This is most often done by cutting approximately 2cm above the bikini (pubic hair) line in the lower abdomen. After entering the abdomen, a similar cut is made across the lower uterus to enter the uterus and deliver the baby and the placenta. This is referred to as a Lower Uterine Segment Caesarean Section. In some selected cases a vertical (up and down) incision is required on the body of the uterus to enter the uterus and deliver the baby and placenta. This is referred to as a Classical Caesarean Section. Occasionally, forceps may be needed to assist the delivery of the baby.D. Risks and complications of this procedureThere are risks and complications with this procedure. They include but are not limited to the following.Common risks and complications include:• infections can occur in the operation site or pelvis or

urinary tract, requiring antibiotics and further treatment for a few days

• bleeding is more common if you have been taking blood thinning drugs such as warfarin, aspirin, clopidogrel (Plavix, Iscover, Coplavix), prasugrel (Effient), dipyridamole (Persantin or Asasantin), ticagrelor (Brilinta), ticlopidine (Tilodene), apixaban (Eliquis), dabigatran (Pradaxa), rivaroxaban (Xarelto) or complementary/alternative medicines, such as fish oil and turmeric

• the uterus may not contract properly after the operation. This can lead to excess vaginal bleeding, treated with hormone injection(s) to contract the uterus. In severe cases, it may be necessary to remove the uterus, preventing future pregnancies

• adhesions (band of scar tissue) from surgery may cause relative increase of bowel or bladder injuries in future surgery. This can be a short term or a long term complication and may need further surgery

• increased risk of wound infection, chest infection, heart and lung complications, and blood clot in the leg or lungs for people who are obese and/or smoke

• due to an increased risk of uterine rupture in future pregnancies, subsequent babies are more likely to be delivered by a repeat caesarean section.

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(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Caesarean Section Consent

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Facility: .........................................................................................................

Uncommon risks and complications include:• minor skin cut(s) to the baby, more common in breech

positions (bottom or feet first). The baby’s bottom, face or body may be cut when the uterus is cut. This usually heals quickly, treated with a band-aid

• injury to other organs such as the ureter(s) (tube leading from kidney to bladder) bladder or bowel. Further surgery may be needed to repair the injuries

• the wound may not heal normally. The scar can be thickened and red and may be painful. This is permanent and can be disfiguring

• adhesions may form and cause bowel obstruction in future• blood clot in the leg (DVT) causing pain and swelling. In

rare cases, part of the clot may break off and go to the lungs• the scar may rupture (burst) in future pregnancies or during

labour. The risk is highest if the cut is made down the uterus rather than across the lower part of the uterus. Scar rupture can be fatal or lead to hysterectomy as a lifesaving measure

• fertility may be reduced after a caesarean section• small areas of the lung can collapse, increasing the

risk of chest infection. This may need antibiotics and physiotherapy

• heart attack or stroke could occur due to the strain on the heart.

Rare risks and complications include:• in future pregnancies, there is a slightly higher risk of your

placenta being low (placenta previa) and/or your placenta grows into the uterine wall (placenta accreta). This requires a repeat caesarean section for the next delivery and blood transfusion may be needed. At times removal of the uterus and repair of the bladder and other organs may be required

• severe bleeding from large blood vessels about the uterus, which will need emergency surgery to repair the damaged blood vessels. A blood transfusion may be required to replace blood loss. Rarely, in severe cases, the uterus may have to be removed, stopping future pregnancies

• bowel blockage after the operation. This may be temporary or longer term. If it doesn’t get better with initial treatment, bowel surgery may be necessary which may include a colostomy. This can be temporary or permanent

• poor wound healing and the wound may burst, which may require long term wound care with dressings and antibiotics, or a hernia i.e. rupture can form in the long term. This may need repair by further surgery

• death as a result of this procedure is possible.

E. Specific risks for you in having this procedure(Doctor/Clinician to document in space provided. Continue in Medical Record if necessary):

F. Risks of not having this procedure(Doctor/Clinician to document in space provided. Continue in Medical Record if necessary):

G. Alternative procedure, treatment or investigation options

(Doctor/Clinician to document in space provided. Continue in Medical Record if necessary):

H. AnaestheticThis procedure may require an anaesthetic (doctor/clinician to document type of anaesthetic discussed):

I. Anticoagulant/Antiplatelet checklistInformation to discuss with your doctor/clinician about blood thinning drugs:Aspirin Yes NoAntiplatelet agents YES NoClopidogrel, Prasugrel, Ticagrelor, Dipyridamole, Other.If the procedure is elective, can the Yes NO antiplatelet be withheld and the patient maintained on aspirin alone for 7 days prior?Date Authorising doctor/clinician ordered antiplatelet ceased/to be ceased:Warfarin/Dabigatran/Rivaroxaban/ YES No Apixaban/Heparins/Other new anticoagulantsIf elective procedure, can all anticoagulation Yes No be ceased before the procedure?Where there have been changes (i.e. ceased, Yes No withheld) to the above drugs, is there a management plan documented in the patient’s medical record?

v6.00 - 09/2017

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(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Caesarean Section Consent

© The S

tate of Queensland (Q

ueensland Health) 2017

Except as perm

itted under the Copyright A

ct 1968, no part of this work m

ay be reproduced com

municated or adapted w

ithout permission from

Queensland H

ealthTo request perm

ission email: ip.officer@

health.qld.gov.au

J. Patient/Substitute decision-maker consentI acknowledge the doctor/clinician has explained:• my/the patient’s medical condition and the proposed

procedure/treatment/investigation may require and include additional treatment if the doctor/clinician finds something unexpected. I understand the risks and benefits, including the risks specific to me

• my/the patient’s requirement for anaesthetic for this procedure/treatment/investigation - I understand the risks associated with anaesthetic, including the risks specific to me (see Anaesthetic information sheet)

• my/the patient has alternative procedure/treatment/investigation options

• my/the patient’s prognosis, and the risks of not having the procedure/treatment/investigation

• no guarantee has been made that the procedure/treatment/investigation will improve my/the patient’s condition even though it has been carried out with due professional care

• my/the patient’s procedure/treatment/investigation may include a blood transfusion

• my/the patient’s tissues/blood may be removed and be used for diagnosis/management of my condition, stored and disposed of sensitively by the hospital

• if an immediate life-threatening event happens during my/the patient’s procedure/treatment/investigation, I/the patient will be treated based on my discussions with the doctor/clinician or Acute Resuscitation Plan

• a doctor/clinician other than the consultant/specialist may conduct the procedure/treatment/investigation. I understand this could be a doctor undergoing further training who will be supervised according to relevant professional body guidelines.

I/the patient was able to ask questions and raise concerns with the doctor/clinician about my/the patient’s condition, the proposed procedure/treatment and its risks, and my/the patient’s treatment options. My questions and concerns have been discussed and answered to my satisfaction.I/the patient understand I have the right to change my mind at any time, including after I have signed this form but, preferably following a discussion with a doctor/clinician.I/the patient understand image(s) or video footage may be recorded as part of and during my procedure and that these image(s) or video(s) will assist the doctor/clinician to provide appropriate treatment.On the basis of the above statements,I consent to having this procedure.Name of patient:

Signature: Date:

I consent to:Name of patient having procedure:

Name of substitute decision-maker:

Signature: Date:

I have received the following information sheet(s): ‘About your anaesthetic’ ‘Epidural and spinal anaesthetic’ ‘Caesarean section’ ‘Blood and blood products transfusion’

K. Interpreter’s statementI have:

provided a sight translation translated as per clinician explanation in:

Patient’s language:of this consent form and assisted in the provision of any verbal and written information given to the patient/substitute decision-maker by the doctor/clinician.

Name of patient:

Language of patient:

Name of Interpreter service:

Name of Interpreter:

Interpreter’s signature: Date:

L. Doctor/Clinician/Delegate statementInformation for doctor/clinician/delegate:The information contained within this form is not, and is not intended to be, a substitute for direct communication between the doctor/clinician/delegate and the patient/substitute decision-maker regarding the medical procedure, treatment or investigation described in this form. I have explained to the patient all the content in this patient consent form and I am of the opinion that the patient/substitute decision-maker has understood the information.Name of doctor/clinician/delegate:

Designation:

Signature: Date:

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(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Caesarean Section Consent

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3. What are the specific risks of this procedure? (continued)

• the uterus may not contract properly after the operation. This can lead to excess vaginal bleeding, treated with hormone injection(s) to contract the uterus. In severe cases, it may be necessary to remove the uterus, preventing future pregnancies

• adhesions (band of scar tissue) from surgery may cause relative increase of bowel or bladder injuries in future surgery. This can be a short term or a long term complication and may need further surgery

• increased risk of wound infection, chest infection, heart and lung complications, and blood clot in the leg or lungs for people who are obese and/or smoke

• due to an increased risk of uterine rupture in future pregnancies, subsequent babies are more likely to be delivered by a repeat caesarean section.

Uncommon risks and complications include:• minor skin cut(s) to the baby, more common

in breech positions (bottom or feet first). The baby’s bottom, face or body may be cut when the uterus is cut. This usually heals quickly, treated with a band-aid

• injury to other organs such as the ureter(s) (tube leading from kidney to bladder) bladder or bowel. Further surgery may be needed to repair the injuries

• the wound may not heal normally. The scar can be thickened and red and may be painful. This is permanent and can be disfiguring

• adhesions may form and cause bowel obstruction in future

• blood clot in the leg (DVT) causing pain and swelling. In rare cases, part of the clot may break off and go to the lungs

• the scar may rupture (burst) in future pregnancies or during labour. The risk is highest if the cut is made down the uterus rather than across the lower part of the uterus. Scar rupture can be fatal or lead to hysterectomy as a lifesaving measure

1. What is this procedure and how will it help me?Caesarean section is an operation performed to deliver the baby from the uterus. This is most often done by cutting approximately 2cm above the bikini (pubic hair) line in the lower abdomen. After entering the abdomen, a similar cut is made across the lower uterus to enter the uterus and deliver the baby and the placenta. This is referred to as a Lower Uterine Segment Caesarean Section. In some selected cases a vertical (up and down) incision is required on the body of the uterus to enter the uterus and deliver the baby and placenta. This is referred to as a Classical Caesarean Section. Occasionally, forceps may be needed to assist the delivery of the baby.

2. My anaestheticThis procedure will require an anaesthetic. For more information about the anaesthetic and the risks involved, please refer to the anaesthetic information sheet that has been provided to you. Discuss any concerns with your clinician.

If you have not been given an anaesthetic sheet, ask for one.

3. What are the specific risks of this procedure?There are risks and complications with this procedure. They include but are not limited to the following.

Common risks and complications include:• infections can occur in the operation site or

pelvis or urinary tract, requiring antibiotics and further treatment for a few days

• bleeding is more common if you have been taking blood thinning drugs such as warfarin, aspirin, clopidogrel (Plavix, Iscover, Coplavix), prasugrel (Effient), dipyridamole (Persantin or Asasantin), ticagrelor (Brilinta), ticlopidine (Tilodene), apixaban (Eliquis), dabigatran (Pradaxa), rivaroxaban (Xarelto) or complementary/alternative medicines, such as fish oil and turmeric

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Give this patient information sheet to the patient or substitute decision-maker(s) to read carefully and allow time to ask any questions about the procedure.

Caesarean sectionInformed consent: patient information

Department of Health Caesarean section patient information v6.00 09/2017 Page 1 of 2

6. Who will be performing my procedure?A doctor/clinician other than the consultant or specialist may conduct the procedure/treatment/investigation. I understand this could be a doctor/clinician undergoing further training. All surgical trainees are supervised according to the relevant professional body guidelines.

If you have any concerns about which doctor/clinician will be performing your procedure please discuss the concerns with your doctor/clinician.

7. Useful sources of informationHospital care: before, during and after is available on the Queensland Health website: www.qld.gov.au/health/services/hospital-care/before-after/index.html

You can read about:• Healthcare choices• Hospital admission• Medical records• During your stay• Practical information• Going home• Compliments and complaints

8. Questions to ask my doctor/clinicianPlease ask your doctor/clinician if you do not understand any aspect of the information in this patient information sheet or any other information you have been given about your condition, treatment options and proposed procedure.

9. Contact us

3. What are the specific risks of this procedure? (continued)

• fertility may be reduced after a caesarean section

• small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy

• heart attack or stroke could occur due to the strain on the heart.

Rare risks and complications include:• in future pregnancies, there is a slightly higher

risk of your placenta being low (placenta previa) and/or your placenta grows into the uterine wall (placenta accreta). This requires a repeat caesarean section for the next delivery and blood transfusion may be needed. At times removal of the uterus and repair of the bladder and other organs may be required

• severe bleeding from large blood vessels about the uterus, which will need emergency surgery to repair the damaged blood vessels. A blood transfusion may be required to replace blood loss. Rarely, in severe cases, the uterus may have to be removed, stopping future pregnancies

• bowel blockage after the operation. This may be temporary or longer term. If it doesn’t get better with initial treatment, bowel surgery may be necessary which may include a colostomy. This can be temporary or permanent

• poor wound healing and the wound may burst, which may require long term wound care with dressings and antibiotics, or a hernia i.e. rupture can form in the long term. This may need repair by further surgery

• death as a result of this procedure is possible.

4. What are the risks specific to me?There may also be risks specific to your individual condition and circumstances. Please discuss these with your clinician and ensure they are written on the consent form before you sign it.

5. What are the risks of not having this procedure?There may be consequences if you choose not to have the proposed procedure/treatment/investigation. Please discuss these with your clinician. If you choose not to have the procedure you will not be required to sign a consent form.

Department of Health Caesarean section patient information v6.00 09/2017 Page 2 of 2