____ I request a Manual Vacuum Aspiration (MVA), a procedure that will empty my uterus. This procedure may be used as an aspiration abortion or as treatment for a miscarriage or a failed medication abortion.

____ I understand that if I am pregnant, my three options regarding this pregnancy are parenthood, adoption, and abortion. I understand that if I am pregnant, the MVA will end my pregnancy.

____ I understand that before the MVA, I may have blood tests done to check me for anemia and I will have to document my Rh type by donor card, prior blood test or a new blood test. If I am Rh negative, I will get a shot of MicRhogam.

____ I understand that I might be offered 2 medications before the MVA: Ibuprofen to lessen the cramping and misoprostol to help open my cervix. I will have local anesthesia with lidocaine injected. To the best of my knowledge, I am not allergic to Ibuprofen, misoprostol, or lidocaine.

____ I understand that the possible complications from MVA include: incomplete emptying of my uterus, infection, bleeding, allergic reaction and perforation.

____ I have read this form and have had time to think about it. I have had all of my questions answered.

____ I have been given an information sheet explaining how and when to get help should a question or problem arise after the procedure.

____ In the event of an unexpected complication during the MVA, I request and authorize the physician to do whatever is needed to protect my health and welfare.

____ I hereby consent that _____________________________ do the procedure “manual vacuum aspiration” for me.

Signature of patient: _____________________________  Date: ____________

Witness: _______________________________________  Date: ____________

Today ________________ you had a procedure called an “aspiration abortion”. You will probably feel fine when you go home. You can go back to your regular activities as soon as you want to. You can take a shower and wash your hair as soon as you want to. You can eat normally, although you may still feel nauseated for another few days.

Follow-up visit: You have an appointment in 1 week, ________________ at _______am/pm.

Are there things you should not do? Yes! Until you come back next week, do not put anything in your vagina. To be safe, do not use tampons, do not douche, and do not have sex.

WHAT TO EXPECT

Vaginal Bleeding: You can expect to have bleeding for up to 2 weeks. It is common for the bleeding to stop and start for several weeks after the abortion. Some women have no bleeding for 2 or 3 days and then begin to have bleeding like a period. Other women have only spotting for a few days and then no more bleeding at all. If you exercise or have a lot of activity, you may notice the bleeding increases; this is not dangerous.

Cramping: Some women have cramps off and on during the week following an abortion. You can use pain medication like Tylenol, Ibuprofen (Motrin or Advil), or Naproxen (Aleve or Nasprosyn). You can also use a heating pad, or drink some warm tea.

Sadness or very emotional: Most women feel very relieved when the abortion is over. Some women also feel sad, feel like crying, or are moody after an abortion. These feelings are partly from the changes in hormones, now that you are no longer pregnant. Feeling emotional at this time is normal. If you think your emotions are not what they should be, please talk to us.

When will your period come back? You can expect a period in 4-8 weeks. It is not the same for all women.

WHAT ARE DANGER SIGNS?

Heavy bleeding: If you are soaking through more than 2 maxi pads an hour for more than 2 hours.

Severe cramps: Cramps that are getting stronger and are not helped by pain medication.

Fever: If your temperature is higher than 101 degrees.

EMERGENCY CONTACT: I have a 24-hour beeper:_________________. If you have any questions, think something is going wrong, or think you have an emergency, page me and I will call you back. I know this may be a tough time for you, so if you forget something, or are worried, call me!

PREGNANCY PREVENTION: You can get pregnant before your period comes back, so it is important to use a birth control method whenever you have sex. If you have sex without protection, you can use Emergency Contraception (EC) to prevent another pregnancy. I have given you a prescription for _________________________________.

Hormonal Birth Control: If you want to use birth control pills, the ring, or the patch, I have given you a prescription. You should start this on Sunday ____________________________, even if you are still bleeding.