Informed Consent for Surgical Management of Miscarriage

Procedure Name

Form Sections

Section 1info grid

Clinical Facility Name

Attending Obstetrician / Gynecologist

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Surgical Procedure

Anesthesia Method

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Section 3list block

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Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Physician Signature

Informed Consent for Surgical Management of Miscarriage

Patient and Facility Information

Clinical Facility Name

Attending Obstetrician / Gynecologist

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Surgical Procedure

Anesthesia Method

Nature and Purpose of the Procedure

This document records informed consent for the surgical management of a miscarriage. The procedure, commonly known as dilation and curettage (D&C) or suction curettage, is performed under appropriate anesthesia. The physician dilates (widens) the cervix and uses suction or surgical instruments to gently clear pregnancy tissue from the uterus. The clinical purpose of the procedure is to resolve incomplete miscarriage, manage persistent bleeding, and prevent intrauterine infection.

Material Risks and Potential Complications

Uterine perforation: inadvertent puncture of the uterine wall by surgical instruments, occurring in less than 1 percent of cases. This may require observation, laparoscopic evaluation, or secondary repair.

Bleeding or hemorrhage, which may require medical treatment, uterine packing, or in rare cases, blood transfusion.

Infection of the uterine cavity (endometritis), requiring antibiotic therapy.

Asherman's syndrome: formation of scar tissue within the uterine cavity that can affect future menstrual patterns or fertility, requiring secondary diagnostic hysteroscopy.

Cervical laceration or tear, which may require sutures to repair.

Retained tissue: incomplete removal of pregnancy tissue, requiring a secondary surgical procedure or medication to resolve.

Expected Benefits

Expected benefits include the complete and controlled evacuation of retained pregnancy tissue, prompt reduction in heavy vaginal bleeding, prevention of severe pelvic infection, and support for physical recovery.

Reasonable Alternatives

Expectant management: waiting for the body to pass the tissue naturally, which requires close clinical monitoring.

Medical management: using prescription medication to stimulate uterine contractions and expel the tissue.

Surgical intervention under alternative anesthesia methods.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Physician Signature

Document ID: CC-PENDING

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