Sample Epidural Consent Form

CONSENT TO EPIDURAL FOR LABOR PAIN CONTROL AND/OR CESAREAN SECTION

1. I authorize the performance upon _________ of the following procedure ______________ performed under the direction of ______(physician's name).

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

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

• Failure to relieve pain.
• Hypotension (low blood pressure).
• Postdural puncture (spinal) headache which may require medical therapy.
• Persistent area of numbness and/or weakness of the lower extremities.
• Temporary nausea and vomiting.
• Breakage of needles, catheters, etc. possibly requiring surgery.
• Hematoma (blood clot) possibly requiring surgery.
• Infection.
• 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).
• Back pain.
• Fetal distress resulting from one of the above complications.

4. I consent to the performance of procedures in addition to or different from those now contemplated, whether 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 procedure, 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.

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