YOU SHOULD HAVE:
A prescription for post-operative pain relief
Postoperative instructions
Post-operative appointment.
VBASC Patient’s only – Patient’s rights and responsibilities, Advance directives policy, notice of financial interest in VBASC.

PREGNANCY RISK WARNING: PLEASE Notify us if there is ANY risk of pregnancy before your sterilization procedure. You must be totally celibate (avoid ALL intercourse) following the menses just before your surgical procedure. If a woman is 6-8 days pregnant, her pregnancy test might still be negative. To avoid this issue, DO NOT HAVE SEX FOLLOWING THE PERIOD BEFORE YOUR PROCEDURE. As a rule, the sterilization will not affect an undetected pregnancy and it would continue. There would be the normal underlying risk of both miscarriage as well as birth defects – the sterilization procedure is not known to increase these risks.

STERILIZATION COUNSELING: You have carefully considered sterilization now request that it be done. You appear to understand your options, the risks, benefits, and the failure rate and consequences of the procedure.

• The decision to have a bilateral tubal ligation is entirely up to you.
• You have other Birth Control Options including Oral, injectable, implantables & barriers.
• That procedure cannot be guaranteed and has a predictable failure rate of about 1 per 200 cases.
• Failures may be either intrauterine or ectopic.
• Regarding the option of male sterilization (and offer to refer to a Urologist)was provided.
• The Various methods of Sterilization have been discussed with the patient and she has consented to any of the following alone or in combination – Modified Pomeroy technique, Laparoscopic Electrocautery, Laparoscopic Filshie Clip.
• That some women have psychologic reactions and you may have feelings of regret following sterilization.
• The intended permanence of the procedure and the fact that attempts at reversal involve a much more extensive and expensive procedure that is not always successful.

ADDITIONAL RISKS:

• Bleeding, Hemorrhage, Blood transfusion, transfusion reactions, hepatitis, and AIDS.
• Injury to internal organs including (but not limited to) bowel, bladder, ureters and blood vessels.
• Life-threatening complications, anesthesia complications or death.
• Possible need to extend or expand the procedure into a larger procedure.

QUESTIONS: You have had an opportunity to ask questions and you have indicated your questions have been answered.
PLAN: Proceed with Bilateral Tubal Ligation / Elective Sterilization in light of your informed request and consent.

ALTERNATIVES:
Mirena IUD.
Hormone methods: Birth Control Pills, Skin Patch or the Intravaginal Ring.
Condoms, Barrier methods.

RISKS: This procedure may subject you to a variety of discomforts and risks. Most patients have surgery with little difficulty, but problems can happen ranging from minor to fatal. These include nausea, vomiting, pain, bleeding, blood transfusion (including risks of hepatitis and AIDS), infection, poor healing, hernia, or formation of adhesions. Unexpected reactions may occur from any drug or anesthetic given.

MORE RISKS: Unintended surgical or burn injury may occur to other pelvic or abdominal structures such as the opening of the vagina, vaginal sidewall, cervix, fallopian tubes, ovaries, bladder, ureter (the tube from kidney to the bladder), or bowel. Nerves going from the pelvis to the legs may rarely be injured. Any such injury may require immediate or later additional surgery to correct the problem. Dangerous blood clots may form in the legs or lungs.

LIMITATIONS: You should understand that if before surgery you have relationship problems, sexual problems, a psychological/psychiatric disorder, or a strong belief that the ability to have children is important to a woman’s identity, these issues all clearly increase the risk of psychological or sexual problems after surgery. It is very likely that laparoscopic surgery will NOT help social, sexual or psychological conditions.

FINALLY: You must understand that it is impossible to list every possible undesirable effect and that the condition for which surgery is done is not always cured or significantly improved, and in some cases may be even worse.

RECOVERY: You may not be fully recovered from this surgery for three to six weeks. You have been given a full opportunity to ask questions and you must indicate your questions have been answered. PLEASE READ THE INSTRUCTIONS BELOW.

For further information on this subject go to my website at www.vbGYN.com and Under the heading PROCEDURES on the first page, there is a link to the most recent summary on ABLATION by the American College of Obstetrics and Gynecology.

PREOPERATIVE INSTRUCTIONS: (Outpatient Surgery).
BEFORE SURGERY: Call your surgeon if you have questions or any change in your physical condition. You should call even if you have just a scratchy throat.
MEDICATIONS: Ask about your medications. If you take aspirin, please ask your doctor if and when you should stop taking it prior to surgery.
PRE-OP PHONE CALL: Expect a call form an Ambulatory Surgery Center nurse 1-4 days before surgery. She will call you to confirm the time of your surgery, give you instructions, obtain a health history, and tell you what medications you should take if you take any on a regular basis. You may reach this nurse by paging her beeper at 680-0688 and she will call you back. After 4 PM please call 496-8934.
PRE-OP TESTS: Laboratory test, x-rays, and other diagnostic test ordered by your physicians must be completed three to ten days prior to your scheduled surgery date. This will give your medical team time to review the results of any pre-operative testing.
WHEN TO STOP EATING: All adults may have solid foods until midnight the night before surgery. Please avoid heavy, greasy foods. After midnight, you are AVOID ALL food, milk products or pulp containing liquids (OJ, grapefruit juice) of any kind.
WHEN TO STOP DRINKING: Clear liquids (water, Sprite, 7-up, apple juice, coffee with out cream) are allowed and encouraged until three (3) hours prior to the time of surgery. No mints, lozenges, gum, or hard candy.
PLAN FOR AFTER SURGERY:
Read your post-op instructions BEFORE your surgery.
Arrange for a ride home and someone to care for you after surgery.
You must have a responsible adult to drive you home and stay with you for 24 hours after surgery.
We encourage your caregiver to stay at the center.
DAY OF SURGERY:
WEAR CASUAL CLOTHING: We’ll provide a gown, robe, and slippers for your surgery.
ARRIVE ON TIME: Please arrive at the time instructed by the pre-op call room nurse or by your surgeon, which is usually One hour and 45 minutes before the scheduled operation. Please be prompt. Your admission process is part of the surgery schedule.
LEAVE CONTACT-LENSES HOME: If you must bring them, bring a storage case.
LEAVE AT HOME: all jewelry, including any piercings, and valuables.
BRING INSURANCE FORMS: (completed) if you haven’t already mailed them to us.
BRING INSURANCE ID CARD: and any papers given to you by your Doctor.
VENDING MACHINES: Complimentary beverages and vending machines are available in the waiting room for visitors.
WIRELESS INTERNET: In addition to two internet connected computers in the waiting area, there is an unsecured wireless network (SSID is VBASC) that is available to those with laptop computers.

FOLLOWUP COUNSELING: Please return to our office for your post-operative check-up at 10-14 days following surgery. CALL US IMMEDIATELY IN THE EVENT OF HEAVY VAGINAL BLEEDING, TEMPERATURE OVER 100 DEGREES, STEADILY WORSENING PAIN OR IF YOU ARE CONCERNED REGARDING A POSSIBLE COMPLICATION.
POSTOPERATIVE APPOINTMENT: If you have not already scheduled your post-op appointment, please call our office 1-4 days following your surgery to schedule a follow-up appointment. For further information on this subject go to my website at www.vbGYN.com.