Epidural consent form

There was recent conversations regarding informed consent. Often times if a mom chooses to get an epidural it will be after she has been in a situation where she is hurting and it is hard to make a decision much less read the form- so here is a form from http://www.gentlebirth.org/archives/epdrlrsk.html for you to read now so you understand the risks involved.

Epidural Consent Form

Here’s the consent form I mentioned a while back. The only thing I’d like to see added is increased c-section rate, which seems to finally be proven.


1. I authorize the performance upon _________ of the following

procedure ______________ performed under the direction of

______(physician’s name).

2. I consent to the administration of local anesthetics, narcotics,

and/or other medications into the epidural space.

3. I understand that the following, among others, are possible

complications or risks of the procedure and that while they are

uncommon, they have been reported in the medical literature:

-Failure to relieve pain.

-Hypotension (low blood pressure).

-Postdural puncture (spinal) headache which may require

medical therapy.

-Persistent area of numbness and/or weakness of the lower


-Temporary nausea and vomiting.

-Breakage of needles, catheters, etc. possibly requiring


-Hematoma (blood clot) possibly requiring surgery.


-Rapid absorption of local anesthetics causing dizziness

and seizures.

-Temporary total spinal anesthesia (requiring life

support systems).

-Respiratory and/or cardiac arrest (requiring life

support systems).

-Back pain.

-Fetal distress resulting from one of the above complications.

4. I consent to the performance of procedures in addition to or

different from those now contemplated, whether or not arising from

presently unforeseen conditions, which the above named doctor or his

associates or assistants including residents, may consider necessary or

advisable in the course of the procedure.

5. The nature and purpose of the procedure, possible alternative

methods of treatments, the risks involved and the possibility of

complications have been fully explained to me. I understand that no

guarantee or assurance has been given by anyone as to the results that

may be obtained.

Notes from Midwifery Today tape on epidurals

After 7 hours on an epidural, the woman’s temp is up 2.1 deg. F, which is considered a maternal fever, which requires a neonate septic workup.

Of 96 first-time moms, 0 w/o epidural had a c-sect., 25 w/ had a c-sect. Of those getting epidurals < 3 cm, 33% had c-sects, 3-4 cm, 26%, > 5 cm, 0% MORAL – try to wait until 5 cm before epidural.

Problems with epidurals: 5% got no pain relief; 5% got inadequate pain relief, often had windows of sensation, which are just as annoying as all over pain.

Epidurals require catheters, which can require antibiotics, which may interfere with nursing.

Another study of 11,000 women having epidurals showed that 18% of women had chronic backache within 6 months of birth, lasting > 3 months. Of those with chronic backache, only 10% didn’t have an epidural.

Lactation consultants say that nipples don’t get erect for 24 hours after end of epidural. Newborns can’t get a good latch. (Ref: Dr. Edie? Laurence, “Measuring Effects of Breastfeeding Success and Epidurals”, U. Rochester.)

Rare complications of epidurals: cardiac arrest, respiratory paralysis, convulsions (most often from high spinals or intravascular injection). Other complications, 9 had spinal headache for 6 weeks, 5 for a full year.

Ways to minimize risks: Choose attendant w/low -sect. rate. One study showed that 46% of primips have epidurals. 1% of “clinic” patients have c-sects. 20% or private patients. If you get an epidural, make sure the facility has emergency c-sect. available and full resuscitation team. For a first baby, posterior or VBAC, delay epidural until after active labor is well established.

Robbie Davis-Floyd says “Women’s satisfaction with the birth experience is directly related to her sense of having mastered it.”

You lose endorphins and euphoria.