Sample Epidural Consent Form for Labor Pain

Consent for Epidural to Control Labor Pain

Before you have an epidural, you must sign a consent form. This is a legal paper that says your doctor has told· you about your procedure and any risks you are taking. By signing this form you are saying that you agree to have the procedure, know alternatives to having the procedure and know the risks involved. Ask your doctor about any concerns you have before you sign this form.

1. I authorize the performance of an epidural performed under the direction of (doctor’s name—anesthesiologist).

2. I consent to the administration of anesthesia, local anesthetics, narcotics, and/or other medicines into the epidural space.

3. I understand that the following, among others, are possible complications or risks of the epidural and that while they are uncommon, they have been reported in the medical literature:

  • Failure to relieve labor pain.
  • Hypotension (low blood pressure).
  • Back pain.
  • Consent for Epidural to Control Labor Pain

    Before you have an epidural, you must sign a consent form. This is a legal paper that says your doctor has told· you about your procedure and any risks you are taking. By signing this form you are saying that you agree to have the procedure, know alternatives to having the procedure and know the risks involved. Ask your doctor about any concerns you have before you sign this form.

    1. I authorize the performance of an epidural performed under the direction of (doctor’s name—anesthesiologist).

    2. I consent to the administration of anesthesia, local anesthetics, narcotics, and/or other medicines into the epidural space.

    3. I understand that the following, among others, are possible complications or risks of the epidural and that while they are uncommon, they have been reported in the medical literature:

    • Failure to relieve labor pain.
    • Hypotension (low blood pressure).
    • Back pain.
    • Temporary nausea and vomiting.
    • Breakage of needles, catheters, etc. possibly requiring surgery.
    • Infection.
    • Hematoma (blood clot) possibly requiring surgery.
    • Postdural puncture (spinal) headache which may require medical therapy.
    • Persistent area of numbness and/or weakness of the lower extremities (legs).
    • Temporary nausea and vomiting.
    • Rapid absorption of local anesthetics causing dizziness and seizures.
    • Temporary total spinal anesthesia (requiring life support systems).
    • Respiratory and/or cardiac arrest (requiring life support systems).
    • Fetal distress resulting from one of the above complications.

    4. I consent to the performance of the epidural in addition to or different from those now contemplated, wether or not arising from presently unforeseen conditions, which the above named doctor or his associates or assistants including residents, may consider necessary or advisable in the course of the procedure.

    5. The nature and purpose of the epidural, possible alternative methods of treatments, the risks involved and the possibility of complications have been fully explained to me. I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained.

    Placement of epidural injection

Comments

  1. Mrs S Hookway says:

    My daughter had an epidural during her labour and didn’t sign a consent form. She is now suffering from post dural complications she has had a blood patch done but has been told that if that doesn’t work they won’t be able to do another one

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