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NIH Consensus Statement  March 29, 2006

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ARISTA OB/GYN

I, ________________________, have requested a primary cesarean section rather than a trial of labor and possible vaginal delivery. My doctor and I have discussed the risks, benefits and complications of both cesarean birth and vaginal delivery. As well as, alternate methods of delivery (vaginal). We believe that elective primary cesarean delivery in healthy women who plan small families is safe. I understand that the rigorous scientific evidence is not available at this time to demonstrate a clear benefit of cesarean delivery over vaginal delivery. However, I have been informed of some scientific studies that indicate that the cesarean delivery is safe, cost effective and may prevent pelvic floor damage. I also understand that my doctor has properly exercised nonmaleficence beneficent based clinical judgment in counseling me regarding my patient choice cesarean birth. I freely and voluntarily accept the risks and benefits and I hereby exercise my right of autonomy for me and my baby, to have the elective cesarean birth ( Patient Choice Cesarean Delivery).

Signed:______________________________________________ Date:__________

Witness:_____________________________________________ Date:__________