Amniocentesis Informed Consent

# Amniocentesis Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ **Gestational Age at Procedure:** ___________ **Ordering Provider:** ___________ **Planned Procedure Date:** ___________ --- ## 1. Procedure I, the undersigned patient, consent to amniocentesis performed by my healthcare provider. **Primary indication for amniocentesis:** ___________ Amniocentesis is a procedure in which a thin needle is inserted through the mother's abdominal wall and uterus into the amniotic sac under continuous ultrasound guidance. A small sample of amniotic fluid (approximately 15–20 mL for diagnostic amniocentesis) is withdrawn and sent to the laboratory. The procedure steps include: 1. Real-time ultrasound is performed to locate the fetus, placenta, and an adequate pocket of amniotic fluid. 2. The skin is cleansed with antiseptic solution. 3. Local anesthetic may be applied to the skin. 4. A thin spinal-type needle is advanced under direct ultrasound visualization into the amniotic cavity. 5. Amniotic fluid is slowly withdrawn by syringe. 6. The needle is removed and the fetal heart rate is confirmed by ultrasound. The fluid contains fetal cells (for chromosomal analysis), biochemical markers, and amniotic proteins. No sedation or general anesthesia is required. The procedure typically takes 5–15 minutes. --- ## 2. Indication