This form has been elaborated following the recommendations issued by the Official Board of Physicians of Barcelona (Colegio Oficial de Médicos de Barcelona – COMB)
Dr (attending physician) ..........................................................................................................................................
Has informed (name of the patient) .........................................................................................................................
That having assessed her medical history and having examined the results from all the complementary tests carried
out (laboratory tests, electrocardiogram, etc.), it has been deemed necessary to administer anaesthesia as follows:
......................................................................................................................................................................................
1. GENERAL RISKS
As in any surgical procedure where anaesthesia is required, some risks and complications might occur during the anaesthetic induction, the actual surgical procedure or during the postoperative recovery period.
These risks and complications could lead to cardiac, respiratory, metabolic or neurological alterations, or lead to a state of coma or even death; although the incidence of these events is extremely low (around 0.38/10,000 deliveries and of these only 6% are due to anaesthetic complications).
A series of side effects or disturbances such as sore throat, coughing, hoarse voice, nausea or vomiting, might occur after general anaesthesia; and headache (with an incidence below 1/100) or nerve damage (1/12,000) after the application of spinal anaesthesia; or haematomas following any type of local anaesthesia.
2. SPECIFIC RISKS OF PREGNANCY
A series of physiological facts proper to pregnancy come together in the obstetric patient causing a higher incidence of back pain (not related to the anaesthetic technique), increased gastric acidity and regurgitation, control of the airway and orotracheal intubation more difficult than that of the general population, increased risk for hypotension and greater sensitivity to local anaesthetics.
3. INDIVIDUAL RISKS
As per the personal circumstances:
4. I have been informed of the possibility of an expected situation developing during the procedure that might require a different or additional procedure to that planned initially. In such instance, I hereby authorise the medical team to carry out any medical procedure or act as deemed necessary.
5. I have been informed to follow strictly the following preoperative instructions: to fasten from the suspected initiation of labour or for 10 hours prior to a scheduled C-section, to take my regular medication (unless otherwise instructed by my physician), not to wear any makeup, lipstick or nail polish, to inform the staff of any type of movable prostheses such as contact lenses or dentures) and to inform the staff upon my admittance to the hospital of any anomaly or problem I might have had from my last visit with my doctor/surgeon.
6. Given that the information given to me has been written in a understandable manner and that all my questions have been answered to my entire satisfaction, either when reading or when listening to the information concerning the specific anaesthetic procedure, I hereby AUTHORISE THE DEPARTMENT OF ANAESTHESIOLOGY to carry out the above mentioned anaesthetic procedure.
I understand that the signing and granting of this informed consent form does not waive any of my rights to undertake possible future claims, either legal or medical. I also understand that I am free to withdraw from this consent form at any moment prior to the procedure.
Signature of the patient and/or legal representative:
Mr/Mrs:
ID number:
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Signature of the physician:
Dr:
Licensed under number:
ID number:
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| In Barcelona, on this..........................................................................of..................... |
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