Aid For Women, 24-Hour Form 720 Central Avenue, Kansas City, KS 66101, 913-321-3350 BRING THIS FORM WITH YOU to your appointment.
The "Women's Right To Know" Act of July 1st, 1997 (now K.S.A. 65-6709): Voluntary and informed consent for an elective abortion is required unless it can be shown that you need a therapeutic abortion to save your life because of a medical emergency. For "voluntary and informed consent" we must provide you in writing at least 24 hours prior to your abortion:
• 1. DOCTOR'S NAME (KSA 65-6709(a)(1)) -- Ronald Yeomans, MD. • 2. PROCEDURE DESCRIPTION (KSA 65-6709(a)(2)) -- The most common kind of abortion we do is by suction aspiration. After injecting a local anesthetic around the cervix, a series of tapered dilator rods, each a little wider than the one before, are inserted and removed to stretch the cervix open wider and then insert a cannula tube into the uterus. Suction is then applied to the cannula tube while gently removing the pregnancy tissue from the uterus. We may use a tear-drop shaped curette to dislodge any tissue that may still remain. The uterus is then re-suctioned to remove any remaining tissue. If you do not dilate easily (at 11 weeks LMP or more) we will insert misoprostol tablets between your cheek and gums and have you wait 2-3 hours for cervical dilation. Later, we will do a regular suction aspiration abortion as described. • 3. POSSIBLE COMPLICATIONS (KSA 65-6709(a)(3)) -- a.) Infections, which are usually avoided if the woman observes her follow-up instructions and takes her preventative antibiotics; b.) Unlikely tear in the cervix, which may be repaired with stitches. That may cause an increased risk of premature delivery in the future; c.) Anesthesia or other medication allergic reactions; d.) Perforation of the uterine wall and possibly other organs (less than 0.1%), which may heal themselves or may require surgical repair; e.) An incomplete abortion (approximately 1-2%) or in which blood clots accumulate in the uterus (1%) requiring removal; and finally, f.) Excessive bleeding (less than 0.1%) which may require a blood transfusion. Serious complications are rare. First trimester abortions are safer than carrying to full-term. The mortality rate with legal abortions is 0.91 per 100,000 abortions.1 Homicide of pregnant and post-partum females by their male partners is 1.7 per 100,000.2 Risks to future reproductive health from an abortion are associated with a chlamydia or gonorrhea infection severe enough to cause Fallopian tube scarring (acquired prior to the abortion), or a perforation of the uterus and the resulting hysterectomy that might have to be done (highly unlikely). We are required to untruthfully tell you that abortion causes risks of premature birth and breast cancer. The American Cancer Society says there is NO correlation (no relationship) between abortion and breast cancer.3 Risk of premature birth from damage to your cervix is more likely during full-term labor from cervical lacerations (tears), especially from induced labor with pitocin, and unlikely from an abortion. Also, depression from hormone withdrawal after abortion (the ficticious Post-Abortion Syndrome4 ) is less severe than full-term birth Postpartum Major Depression (PMD). PMD occurs in 10% of all pregnancies.5 • 4. GESTATIONAL AGE (KSA 65-6709(a)(4)) -- When did your Last normal Menstrual Period (LMP) start? __________. Counting from LMP to the time of your appointment with us, how many weeks is that? ___________. Subtracting 2 weeks from that and you will have gestational weeks or weeks from conception. We do NOT count from conception. We count from Last Menstrual Period. Although not relevant since we do non-viable small abortions, we are required to tell you, "No person shall perform or induce an abortion when the unborn child is viable unless such person is a physician and has a documented referral from another physician not financially associated with the physician performing or inducing the abortion and both physicians determine that: (1) The abortion is necessary to preserve the life of the pregnant woman; or (2) a continuation of the pregnancy will cause a substantial and irreversible impairment of a major bodily function of the pregnant woman." • 5. PROBABLE ANATOMICAL & PHYSIOLOGICAL CHARACTERISTICS (KSA 65-6709(a)(5))6 --
Gross apearance & internal development
The brain, spinal cord, and heart begin to develop. Pregnancy test is positive.
Arm and leg buds become visible. The brain develops into five areas and some cranial nerves are visible. The eyes and ear structures begin to form. Tissue forms that develops into the vertebra and some other bones. The heart continues to develop and now beats at a regular rhythm. Rudimentary blood moves through the main vessels.
The eyelids are more developed. External features of the ear begin to take their final shape. The intestines rotate.
Skin pink, delicate; resembles a human being, but head is half of fetus size. Genitals appear well differentiated. Limbs are long and thin. The fetus can make a fist with its fingers.
Hair and nails appear. Fetus is active. Arm-leg ratio now proportionate. Sex determination possible. External sex organs grossly formed. Heart muscle well developed.
*CRL=length of the fetus in millimeters as measured by ultrasound. *LMP=means from the first day of the last menstrual period in weeks.
• 6. COUNSELING ASSISTANCE (KSA 65-6709(a)(6)) – There is counseling assistance for medically-challenged pregnancies (for example, fatal birth defects) and perinatal hospice (dying) services, possibly free. Please call Kansas Department of Health and Environment, Woman's Right to Know information line at 1.888.744.4825 to obtain by mail the "If You Are Pregnant: Directory of Available Services", then page 46, has 4 agencies in Kansas with their web addresses that will help with perinatal hospice. • 7. RISKS OF FULL TERM PREGNANCY (KSA 65-6709(a)(7)) – Risk of maternal death within the first year after delivery is 15.5 per 100,000 live births.7 Possible complications from full term delivery include: a.) Major abdominal surgery (Caesarian section) occurs in 32.9% of all U.S. births8 , which has a mortality of 6 to 18 per 100,000.C-sections9 also put you at more risk of placenta accreta (by placenta growing into C-section scar) which leads to increased bleeding during delivery.10b.) Allergic reactions to anesthetics or other medications. Reactions may produce a fever, rash, and discomfort or, in rare cases, may be life-threatening. c.) Infections. Approximately 4% of women become infected after childbirth and must be treated with antibiotics. If not treated, infections may cause infertility or, in rare cases, may be life-threatening. d.) Heavy bleeding from clotting problems, placental tearing or surgery that requires medical treatment. Fewer than 5% will require a transfusion. e.) Blood clots. Clots in the lungs are the leading cause of maternal death after a live birth. f.) Complications of high blood pressure, pre-eclampsia, account for 15% of all maternal mortalities.11g.) Complications of medication to stop premature labor (fluid in lungs and heart failure). Women who are more likely to have serious complications during and after pregnancy are those with reduced access to prompt medical care and those with poor general health and living conditions. Mild depression occurs in up to 70% of women immediately following childbirth. Up to 10% of women experience depression of a lingering nature after childbirth. • 8. THE Rh FACTOR COMPLICATIONS (Iso-immunization) (KSA 65-6709(a)(8)) – There are four major blood types, (A, B, O, AB) each with a sub-category of Rh-Positive or Rh-Negative. There is approximately a 15% chance that you be Rh-Negative (A-neg, B-neg, O-neg, AB-neg), which would mean that your pregnancy would be 85% likely to be Rh-Positive (A-pos, B-pos, O-pos, AB-pos). When even the tiniest amount of Rh-Positive fetal blood mixes with your own Rh-Negative blood, your immune system attacks the Rh-Positive pregnancy, resulting in compromised fetal health or possibly fetal death. This can be prevented with an injection of Rh Immune Globulin (Rhogam). If you are Rh-Negative you are required at this clinic to receive this Rhogam injection if you have an abortion. There is a cost for the Rhogam injection. • 9. ABORTION ALTERNATIVES (KSA 65-6709(b)(1-2)) – You may continue your pregnancy to birth instead of having an abortion. We can help initiate private adoptions. If you choose adoption, you will need the father's signature to give up his parental rights. Women needing financial assistance to continue the pregnancy may be eligible for Medicaid and Temporary Assistance for Needy Families. For a list of agencies that could help you with a continuing pregnancy, adoptions, and free sonography please call the Kansas Department of Health and Environment's Women's Right to Know information phone line at 1.888.744.4825. • 10. FATHER IS LIABLE FOR CHILD SUPPORT (KSA 65-6709(b)(3)) - the father of your pregnancy is responsible for child support if you decide to continue your pregnancy and he could be tracked down by his Social Security Number through the IRS and Kansas State. Realistically, child support is very difficult to collect and is usually less than what a child costs. • 11. YOU CAN CHANGE YOUR MIND (KSA 65-6709(b)(4)) – You may change your mind to have an abortion anytime prior to actually dilating your cervix without affecting your right to future health care from other physicians, nor will federal or state benefits be lost. • 12. WE MUST UNTRUTHFULLY TELL YOU (KSA 65-6709(b)(5)) – "The abortion will terminate the life of a whole, separate, unique, living human being." This is untruthful because the fetus is quite dependent upon, not separate from, the maternal placental oxygen and nutrient acquisition and kidney's waste disposal. The word "whole" implies "complete" but the fetus is not truly completed until birth. Also, cancer is unique, human and living, yet not deserving of life. • 13. CERTIFICATION (KSA 65-6709(e) – You must sign a form which will state that you have received all of this information. • 14. NO PAYMENT REQUIRED BEFORE 24th HOUR (KSA 65-6709(g)) – by law we cannot require you to pay for the abortion during the 24 hours after receiving this information, but this does not stop us from requiring payment after the 24th hour and before the abortion. By signing below, you acknowledge that you have read and understood the information above, and that you received this information at least 24-hours prior to your abortion (KSA 65-6709(d-e)).
_________________________________________________ Signed and received:May 24, 2013, 9:50:53 am Central Time Patient name. I understand that I cannot legally get an abortion before Sunday, May 26, 2013