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ART & SCIENCE OF OB-GYN P.C.
CONSENT TO AND REQUEST FOR
OBSTETRIC ULTRASOUND

SAFETY: I understand that Ultrasound uses high frequency sound to show a picture of the baby on a monitor. I have been told that this type of ultrasound has not been shown to have any harmful effect on either the baby or the mother.
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(Patient Initials)

PURPOSES: I understand that the use of ultrasound in Obstetrics can provide important information about the pregnancy. The purposes for my 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. I understand I may choose to be told the sonographers impression of the baby’s gender (sex) but I realize this is not always visible or completely reliable
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(Patient Initials)

TECHNICAL DIFFICULTIES: I have been told that 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). I understand that ALL the preceding issues can and do affect how well it is possible to see the baby‘s anatomy.
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(Patient Initials)

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.  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, I 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. I understand that a normal ultrasound examination does NOT reliably rule out all birth defects that I cannot know that my baby is "entirely normal" based on an ultrasound evaluation.
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(Patient Initials)

I have carefully read the above information and I have been given an opportunity to ask questions. I request and consent to the ultrasound examination as it is represented by this document. By signing this consent I acknowledge that I understand and accept the limitations of ultrasound as it is being offered to me.
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(Patient Signature)