Informed Consent

KANSAS 24 HOUR INFORMED CONSENT
• Bring this document with you to your appointment.
• Please read and initial each section and sign your name at the bottom.
• DO NOT mail to Comprehensive Health or Planned Parenthood.

To comply with Kansas Law effective July 1, 1998 (amended July 1, 2009; July 1, 2011), you must receive this Informed Consent at least 24 hours prior to your procedure.

1. Your abortion procedure will be performed by Orrin Moore, M.D. or Allen Palmer, D.O. .  You will have the opportunity to meet with the doctor before your procedure.

2. Estimated Gestation of Pregnancy: Until you have a sonogram to determine how far along the pregnancy is, the best way to estimate the gestation is by the date of your last normal menstrual period.

The final determination will be made by the doctor upon ultrasound examination. If you are between 4 - 14 weeks, the common procedure is Vacuum Aspiration. Medication Abortion is available for pregnancy termination between 4 – 9 weeks. If you are between 15 - 22 weeks the most common procedure is Dilation and Evacuation.

3. Types of Abortion Procedures:

First Trimester (4-13 wks LMP) Vacuum Aspiration- This abortion procedure begins with a local anesthetic given to numb the cervix.  The cervix is then widened using dilators, which are tapered rods that gradually increase in size.  The physician inserts a small tube (cannula), which is attached to an aspiration device.  The device’s suction empties the contents of the uterus through the tube.  The physician may check the walls of the uterus with a curette.  The entire procedure takes less than 10 minutes.  Sensations will vary, but they are mostly described as cramping or discomfort, which generally subsides within a few minutes after the procedure is over.

Early Non-surgical/Medication Abortion (4-9 weeks LMP or up to 63 days) – While in the clinic, a drug, Mifepristone, is given to stop the development of the pregnancy.  One to two days later, at home, a second drug (Misoprostol) is taken, causing the uterus to contract and expel the embryo and placenta.  During this process cramping and bleeding will occur.

Second Trimester (14-22 wks LMP) Dilation and Evacuation- During the initial appointment, the osmotic dilators are inserted into the patient’s cervix to begin the process of slow and gentle dilation of the cervix.  The abortion procedure occurs several hours later, or in some cases one or two days later and involves removal of the pregnancy with forceps.  A suction instrument is used to clean the uterus, and a curette is used to check the uterine walls.  Patients are then monitored in recovery for at least 2 hours following the procedure.

Complications of Abortion- Possible complications include: blood clots accumulating in the uterus, requiring another suction procedure; infections, most of which are easily identified and treated if the woman carefully observes follow-up instructions; a tear in the cervix, which may be repaired with stitches; perforation of the wall of the uterus and/or other organs, which may heal themselves or may require surgical repair or, rarely, hysterectomy; and abortion that is not complete or that does not end the pregnancy may require the procedure to be repeated; excessive bleeding due to failure of the uterus to contract, which may require a blood transfusion; death.  In the second trimester, risks increase with every week of gestation.

4. Risks with terminating a pregnancy vs. carrying a pregnancy to term- Health risks are low with either decision.  There is approximately 1 death for every 167,000 women who have legal abortions and these rare deaths are usually of adverse reactions to anesthesia, heart attacks, or uncontrollable bleeding.  The death rate for a woman carrying to term is about 10 times greater.

5. Your blood type will be determined the day of your appointment.  Approximately 15% of the population is Rh negative.  All Rh-negative women will receive an injection of Rhogam to prevent problems with future pregnancies such as miscarriage, severe fetal anemia or permanent fetal damage.  The cost of the Rhogam is $75 - $125 depending upon fetal age.

6. According to Kansas law effective July 1, 1998 and amended July 1, 2009; July 1, 2011, Comprehensive Health of Planned Parenthood of Kansas and Mid-Missouri is required to provide you with the following state-mandated, state-written information:

A) Informational materials are available in printed form and online at http://www.womansrighttoknow.org/   and http://www.kansaswomansrighttoknow.org/, describing the fetus and listing agencies which offer alternatives to abortion with a special section listing adoption services and list providers of free ultrasound services.

B) Alternatives to abortion include parenting, foster care and adoption. Medical assistance benefits may be available for prenatal care, childbirth, and neonatal care. More detailed information on the availability of such assistance is contained in the printed informational materials you received from Comprehensive Health of Planned Parenthood or online at http://www.womansrighttoknow.org/  and http://www.kansaswomansrighttoknow.org/,

C) …“the father of the [fetus] is liable to assist in the support of her child even in instances where he has offered to pay for the abortion.”

D) “the abortion will terminate the life of a whole, separate, unique, living human being.”

E) …“the woman is free to withhold or withdraw her consent to the abortion at any time prior to the invasion of the uterus without affecting her right to future care or treatment and without the loss of any state or federally funded benefits to which she might otherwise be entitled.”

F) “No person shall perform or induce an abortion when the unborn child is viable unless such person is a physician and has a documented referral from another physician not financially associated with the physician performing or inducing the abortion and both physicians determine that: (1) The abortion is necessary to preserve the life of the pregnant woman; or (2) a continuation of the pregnancy will cause a substantial and irreversible impairment of a major bodily function of the pregnant woman.”  And “If the child is born alive, the attending physician has the legal obligation to take all reasonable steps necessary to maintain the life and health of the child.”

7. I received this information at least twenty-four (24) hours prior to my procedure.

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