JTP ab consent

What is a medical abortion?
A medical abortion means using 2 medicines to end a pregnancy.
- Mifepristone is the first medicine – it starts the abortion process. Your pregnancy needs a hormone called progesterone to grow normally. Mifepristone blocks your body’s progesterone.
- The second medicine, misoprostol, opens the opening to your uterus (cervix) and makes your uterus contract in order to expel or push out the pregnancy.
What are the benefits of the medical abortion? It is a safe and effective way to end a pregnancy. It can be done in the privacy of your home and does not require a pelvic exam.
How well does medical abortion work? It depends how far along you are in your pregnancy. The table below tells you how well medical abortion works by week of pregnancy.

Weeks of Pregnancy  |  How Well Medical Abortion Works
8 weeks or less = About 98 out of 100 times
From 8 to 9 weeks = About 96 out of 100 times
From 9 to 10 weeks = About 91 to 93 out of 100 times

Purpose: I understand that the purpose of abortion is to terminate a pregnancy

Risks of Medical Abortion: Medical abortion is safe, but there are risks with any medical procedure. I understand these risks may include:
 • Continuing pregnancy: In some cases, the pregnancy does not end after the medications. Because misoprostol can cause birth defects, if this happens you may need to take more medicine or have a suction procedure (called a “D&C” or “suction abortion”) to complete the abortion.
 • Incomplete abortion: Some of the pregnancy tissue or the pregnancy may be left inside your uterus. This may lead to heavy bleeding, infection, or both. If this happens, you may need a suction procedure, other tests, or treatments.
 • Hemorrhage: You may have too much bleeding or bleed for too long. If this happens we may recommend medicine, a suction procedure, or, rarely, a blood transfusion or surgery to remove the uterus (hysterectomy).
 • Infection: The infection rate from medical abortion is less than 1%. Antibiotics are used to treat the infection, and rarely a suction procedure.
 • Allergic reaction: While rare, some people are allergic to the medicines that are used.
 • Death: Death from medication abortion is very rare. The risk of death from childbirth is about ten times greater.

Side Effects of Medical Abortion: Side effects usually do not last long. They usually need little or no treatment.
 • Cramping: This is normal and is supposed to happen. Cramping is usually worst when the pregnancy is passing. Milder cramps may last a day or 2 after that.
 • Bleeding: This is also normal and is supposed to happen. Bleeding is usually heaviest when the pregnancy is passing.
 • You should call us if you are soaking 2 pads an hour for more than 2 hours in a row. You may bleed or spot for 4 to 6 weeks after the abortion.
 • Fever/chills: The misoprostol can make you feel as if you have a fever. We recommend you do not take your temperature for the first 24 hours. Having a temperature of 99-100°F is okay.
 • It is also common to have chills, diarrhea, nausea, vomiting, headache, dizziness, back pain, and tiredness. These should go away 24 hours after taking misoprostol.

Options: I understand with pregnancy there are three options to think about - abortion, adoption, and parenting. There are two ways to have an abortion, medical abortion and suction abortion. I understand I can talk to the staff about all of these options to help make my decision.

What else do I need to know? A range of emotional responses is normal after abortion care. Emotional problems are uncommon, and when they happen they usually go away quickly. Most women report a sense of relief, although some experience sadness or guilt. However, if you experience depression that lasts for 2 weeks or longer, your provider can give you resources to help you with this process.

Additional Information Regarding “No-Touch” Abortion Protocols
We offer “no-touch" medication abortion which involves no testing (lab work or ultrasound) at our clinic either prior to or after administering the pill. Because we do not, it is important you understand the additional risks, which are very rare, but serious considerations.
1) Foregoing pre-medication ultrasound, prevents your healthcare provider from ruling out:
     a) Ectopic pregnancy: The risk of ectopic pregnancy in patients seeking abortion is rare. We will discuss contraindications to screen out patients at higher risk of ectopic and review symptoms of ectopic
pregnancy. It is important that you understand that the medication we offer does not treat ectopic pregnancy, which, if untreated, can develop into a life-threatening emergency.
     b) Inaccurate pregnancy dating: Although rare, you may be earlier or later in pregnancy than anticipated by last menstrual period. Inaccurate dating may affect the success, side effects, and complication rate of medication abortion. Additionally, if the pregnancy is farther along than anticipated, there may be increased bleeding, cramping, and passage of identifiable fetal tissue.
     c) Early pregnancy loss (miscarriage): An early pregnancy loss may go undetected without an ultrasound. If early pregnancy loss is not diagnosed, you may lose the opportunity for other options for
management. Medication abortion is one option for management of early pregnancy loss.
2) Foregoing pre-abortion lab work and blood draw:
     a) Rh testing and anti-D immunoglobulin: National Abortion Federation (NAF) protocols state that patients who are less than 70 days from the first day of their last menstrual period do not need Rh
testing or anti-D immunoglobulin. Additionally, patients who know their Rh status, are finished childbearing, or decline Rh testing and anti-D immunoglobulin do not need testing.
     b) Testing iron levels/hemoglobin/hematocrit is not routinely needed before first-trimester abortion according to NAF. However, testing may be necessary as indicated by medical history and patient
3) Foregoing post-medication ultrasound: After a medical abortion, there are two ways to make sure you are no longer pregnant. You can have an ultrasound or a pregnancy test (by blood or urine). We do not require a post-abortion ultrasound. In lieu of post-medication ultrasound we will provide pregnancy tests to be taken at home to confirm that you are not pregnant. It is possible for a urine pregnancy test to be positive for up to 4 to 6 weeks after the abortion until the pregnancy hormone completely leaves your body. We will instruct you when to take a test to confirm that you are no longer pregnant. Additionally, we will assess your symptoms and be available to address any concerns you have.

After having considered this information, if you choose to pursue conventional pre and post abortion testing, we would be happy to provide a referral to providers who include these tests as part of their standard of care.

Emergency: I have been given an emergency telephone number to call 24 hours a day for assistance. I agree to call (320) 905-9921 in the event of any problem.

I have read and understand this form. All information I have given is true and correct and I realize that the physician and this facility have relied on such information. All my questions have been answered to my satisfaction. I give my consent voluntarily. No one is forcing me to make this decision. I am aware that I may have a copy of this form at my request.

If patient is under 18 or has a legal guardian:

Signature of Patient (or person authorized to sign for patient):

Leave this empty:

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