A 32-year-old woman, gravida 1 para 0, at 42 weeks gestation is admitted to labor and delivery for spontaneous rupture of membranes and contractions. The patient's pregnancy has been uncomplicated, and she has no chronic medical conditions and takes no medications. Blood pressure is 120/60 mm Hg, pulse is 78/min, and respirations are 12/min. Fetal heart rate monitoring shows a baseline of 130/min, absent variability, and recurrent late decelerations. Intrauterine resuscitation with maternal repositioning and oxygen administration does not improve the fetal heart rate tracing. The cervix is 4 cm dilated and 25% effaced on digital cervical examination. The patient is informed of the need for an emergency cesarean delivery due to significant risk for fetal asphyxia and death. However, she refuses to undergo cesarean delivery. Further discussion reveals that the patient fully understands the risks of refusing the procedure and continues to insist on a vaginal delivery. Which of the following is the most appropriate next step?

Question

A 32-year-old woman, gravida 1 para 0, at 42 weeks gestation is admitted to labor and delivery for spontaneous rupture of membranes and contractions.  The patient's pregnancy has been uncomplicated, and she has no chronic medical conditions and takes no medications.  Blood pressure is 120/60 mm Hg, pulse is 78/min, and respirations are 12/min.  Fetal heart rate monitoring shows a baseline of 130/min, absent variability, and recurrent late decelerations.  Intrauterine resuscitation with maternal repositioning and oxygen administration does not improve the fetal heart rate tracing.  The cervix is 4 cm dilated and 25% effaced on digital cervical examination.  The patient is informed of the need for an emergency cesarean delivery due to significant risk for fetal asphyxia and death.  However, she refuses to undergo cesarean delivery.  Further discussion reveals that the patient fully understands the risks of refusing the procedure and continues to insist on a vaginal delivery.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

This laboring patient has a category III fetal heart rate tracing (ie, absent variability, recurrent late decelerations), a sign of fetal hypoxemia that, if sustained, may lead to fetal demise. Patients with category III fetal heart rate tracings are typically managed with emergency cesarean delivery. Patients have the right to make their own medical decisions as long as they understand the risks and benefits of the procedure (ie, have capacity). Such decisions can become more complicated in the setting of pregnant women, as both the mother and fetus are affected. However, until delivery, the mother has complete autonomy for medical decisions affecting both herself and the fetus, including refusal of treatment (even if this leads to adverse fetal outcomes). In these scenarios, the rights of the mother are considered over those of the fetus (Choices A and B). Therefore, the most appropriate next step is to respect the patient's decision and continue with vaginal delivery. (Choices D and E) Seeking a court order or an alternative decision maker (eg, spouse, parent) may be necessary for patients who lack capacity for their medical decision-making. This patient understands the risks and benefits of refusal of treatment. Educational objective: Pregnant women with capacity have the same right to refuse treatment (eg, emergency cesarean delivery) as nonpregnant patients, even if the decision does not represent the best interests of the fetus. References: Committee Opinion No. 664: refusal of medically recommended treatment during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27214192)

A 32-Year-Old Woman, Gravida 1 Para 0, at 42 Weeks