1101 First Colonial Road, Suite 100
Virginia Beach, Virginia 23454

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ULTRASOUND CONSENT FORM

SAFETY:  
Ultrasound uses high frequency sound to show a picture of the baby on a monitor.This type of ultrasound has not been shown to have any harmful effect on either the baby or the mother. 

PURPOSES:  The use of ultrasound in Obstetrics can provide important information about the pregnancy. The purposes for the ultrasound exam include: Confirming that the baby is moving and has a heart beat, determining the baby's age and estimating the "due date", checking for twins, determining the baby's position, locating and examining the placenta, looking at the volume of amniotic fluid and evaluating the mother for ovarian or uterine tumors. A careful, reasonable effort will also be made to look at the baby’s anatomy. The available images will be reviewed to see if they are reassuring and appear to be normal at the time of the examination.  You may choose to be told by the sonographer her impression of the baby’s gender (sex) but you should realize this is not always visible or completely reliable

TECHNICAL DIFFICULTIES:   The following issues can affect how well the baby’s anatomy can be seen: the baby’s position, age, size and movement, mother’s body type (mild to severe obesity), placental location, abdominal wall scars, low amniotic fluid volume, presence of twins and the shadowing of one part of the baby by another part of the baby (acoustic shadowing). Please understand that ALL the preceding issues can and do affect how well it is possible to see the baby‘s anatomy.

LIMITATIONS:   Approximately 3-5% of all babies are born with a birth defect. Some of the most common conditions expecting parents worry about cannot reliably be seen through an ultrasound examination. Such conditions include cerebral palsy, epilepsy, learning disabilities, some effects of drug or alcohol exposure, infection and disorders of the baby’s blood chemistry – all are generally not visible on ultrasound. Very small heart, spinal, palate (lip) or other defects may not be seen on a reasonably careful ultrasound examination. In most cases we cannot reliably count individual fingers and toes Chromosomal abnormalities such as Down syndrome cannot be reliably ruled out with ultrasound. If no abnormalities are seen, You must understand that the ultrasound exam is considered reassuring because it does reduce my risks that a structural or chromosomal abnormality is present in the baby.  You must understand that a normal ultrasound examination does NOT reliably rule out all birth defects and cannot demonstrate that the baby is "entirely normal" based on an ultrasound evaluation.

You should have an opportunity to ask questions.  Then you may request and consent to the ultrasound examination as it is represented by this summary.  If you choose to have ultrasound at our office you must understand and accept the limitations of ultrasound as it is being offered to me.