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Informed Consent for Prenatal Diagnosis by Amniocentesis
I, _______________________________________________________ want the doctors at Platte
River Perinatal Center to try to get some amniotic fluid from around my fetus so that the
developing baby’s chromosomes, alpha-fetoprotein (AFP), and possibly other specific genetic
factors can be studied. The amniocentesis procedure has been explained to me, and I understand
that a needle will be put into my abdomen and through the wall of my uterus in order to get some
of the amniotic fluid. I also understand and accept the limitations and chances for problems as
stated below.
1) I understand that I may feel some discomfort during the amniocentesis as the needle
passes into and out of my uterus.
2) I understand that there is a chance for needle damage to me and to the fetus. This risk is
thought to be small as the needle is very thin, and the ultrasound is used to find a safe
place to put the needle. It is very unlikely that the baby would have any serious effects
from being stuck by the needle.
3) I understand that approximately 2 in 100 (2%) of women who have the amniocentesis
have problems after it such as cramping, bleeding and/or leaking fluid from the vagina,
and signs of infection. Signs of infection can include fever, aches, and chills. I
understand I should call my doctor’s office if I have any of these problems.
4) I understand that there is less than 1 in 200 (0.5%) chance that I may lose my pregnancy
(miscarry) because of the amniocentesis. The chance for miscarriage in the second
trimester (12 through 24 weeks of pregnancy) is 3 to 4 (3-4%) without having the
procedure. Therefore, most miscarriages that happen after having an amniocentesis
would have happened anyway.
5) I understand that there is less than a 1 in 100 (1%) chance that the doctor may not be able
to get enough amniotic fluid from the first try and may have to try a second time.
Sometimes even the second time is not successful. It is my choice whether or not to have
a second amniocentesis.
6) I understand that there is less than 1 in 100 (1%) chance that the cells from the amniotic
fluid may not grow so that it may not be possible to do the chromosome and other genetic
studies on the sample of fluid. I understand that in this event I may be offered a second
amniocentesis.
7) I understand that there is less than 1 in 200 (0.5%) chance that there may be an error in
the chromosome analysis. Very small differences in the chromosomes may be missed.
There is also a small chance that mother’s cells can get into the sample, which may make
it difficult to get accurate results.
8) I understand that before and during the amniocentesis, ultrasound will be used to examine
the fetus and to find a safe place to put the needle. The ultrasound may not detect all
multiple pregnancies (twins, triplets, etc.) nor all possible birth defects.
9) I understand that in case of a multiple pregnancy, the results may be for only one fetus.
10) I understand that there are many genetic conditions and health problems the fetus may
have that cannot be diagnosed by chromosome studies, alpha-fetoprotein analysis, or
other specific genetic testing which may be done on the fluid.
11) I understand that if my blood type is Rh negative I may need a shot of Rhogam after the
amniocentesis. In some mothers Rh sensitization has happened following amniocentesis.
12) I understand that all abnormal findings will be explained to me. Treatment options will
be discussed. The decision to continue or to have the pregnancy ended is completely
mine.
13) I understand that it is my choice to have or not to have an amniocentesis.
14) I understand that my signature below means that I have read, or have had read to me, the
above information, and I understand it. I have had a chance to discuss it, including the
reason(s) and possible risks of amniocentesis, with a genetic counselor and/or the doctor
performing the procedure. I have received all the information I want about the
amniocentesis. My questions have been answered.
Signed: ___________________________________ Date: ________________________
(Patient)
Signed: ___________________________________ Date: ________________________
(Parent or legal guardian)
Signed: ___________________________________ Date: ________________________
(Witness/Title)