A 26-year-old woman, gravida 1 para 0, at 38 weeks gestation is admitted to the hospital in active labor. Twelve hours after admission, she has a spontaneous vaginal delivery of a baby boy who weighs 3.8 kg (8.4 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The patient did not receive routine prenatal care. She has no chronic medical conditions and no medication allergies. After delivery, the patient is informed that her son will require erythromycin ointment to prevent an eye infection and possible blindness that can be caused by untreated gonorrhea. The patient says her son does not need treatment because she has never had a sexually transmitted infection. Which of the following is the most appropriate response to this patient?

Question

A 26-year-old woman, gravida 1 para 0, at 38 weeks gestation is admitted to the hospital in active labor.  Twelve hours after admission, she has a spontaneous vaginal delivery of a baby boy who weighs 3.8 kg (8.4 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.  The patient did not receive routine prenatal care.  She has no chronic medical conditions and no medication allergies.  After delivery, the patient is informed that her son will require erythromycin ointment to prevent an eye infection and possible blindness that can be caused by untreated gonorrhea.  The patient says her son does not need treatment because she has never had a sexually transmitted infection.  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

This patient is declining recommended treatment for her newborn based on the reasoning that she has not had a sexually transmitted infection (STI). This may reflect a lack of understanding that STIs may be asymptomatic and/or lack of knowledge that preventive treatment is recommended for all newborns. The patient should be counseled that prophylactic erythromycin is recommended for all newborns to prevent blindness from Neisseria gonorrhoeae. As part of the process of informed consent, all necessary information about indications for treatment as well as risks and benefits of accepting and refusing treatment should be provided, and the patient should be encouraged to ask questions. Whenever a patient declines or is hesitant to accept treatment, the initial step is for the physician to assess the patient's knowledge, provide clarification when needed (as in this case), listen to concerns, and understand the specific reasons for the refusal. The process of obtaining informed consent should be conducted in a nonjudgmental and noncoercive way. (Choices A and E) These statements automatically accept or reject the patient's decision without determining her level of understanding, providing needed clarification, and addressing concerns. Responding to treatment refusal should first involve assessing the patient's understanding of the indications, risks, and benefits of treatment. (Choice C) The patient has already asserted that she does not have a sexually transmitted illness, and further discussion on this point is likely to be perceived as condescending, which could undermine trust. Treatment is recommended for all newborns, regardless of the patient's history of being treated for an STI. (Choice D) Although this statement makes a medically valid point, it blames the patient for a worst outcome. Using parental fear and guilt as a coercive tactic should be avoided. Educational objective: The process of informed consent involves discussing the indications, risks, and benefits of treatment. Assessing a patient's understanding of the discussion and responding to specific concerns or confusion is essential to obtaining valid consent. __________ References: Informed consent-it's more than a signature on a piece of paper. (http://www.ncbi.nlm.nih.gov/pubmed/28974311) Ocular prophylaxis for gonococcal ophthalmia neonatorum: updated evidence report and systematic review for the us preventive services task force. (http://www.ncbi.nlm.nih.gov/pubmed/30694309) Parental refusal of vitamin K and neonatal preventive services: a need for surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/28054156)

A 26-Year-Old Woman, Gravida 1 Para 0, at 38 Weeks