A 29-year-old primigravida at 36 weeks gestation comes to the office with her husband for a routine prenatal visit. Her pregnancy has been uncomplicated, and she has no chronic medical conditions. Her only medication is a daily prenatal vitamin. Vital signs are normal. Fundal height is 36 cm, and fetal heart sounds are 150/min on Doppler ultrasound. The patient says she has created a detailed birth plan and would like to have a natural delivery. She says a vaginal birth is necessary for her to feel fully connected to her baby, and she is not interested in receiving any medication to decrease the pain. The patient's wishes are acknowledged and documented in the chart; however, the physician states that unexpected events can occur during labor and delivery that require a cesarean delivery. The patient replies, "A cesarean delivery is not part of my birth plan-I don't want to have one." Which of the following is the most appropriate response?

Question

A 29-year-old primigravida at 36 weeks gestation comes to the office with her husband for a routine prenatal visit.  Her pregnancy has been uncomplicated, and she has no chronic medical conditions.  Her only medication is a daily prenatal vitamin.  Vital signs are normal.  Fundal height is 36 cm, and fetal heart sounds are 150/min on Doppler ultrasound.  The patient says she has created a detailed birth plan and would like to have a natural delivery.  She says a vaginal birth is necessary for her to feel fully connected to her baby, and she is not interested in receiving any medication to decrease the pain.  The patient's wishes are acknowledged and documented in the chart; however, the physician states that unexpected events can occur during labor and delivery that require a cesarean delivery.  The patient replies, "A cesarean delivery is not part of my birth plan-I don't want to have one."  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Although this patient has expressed her wishes for a vaginal delivery, it is the physician's duty to inform her that unexpected complications can occur in normal pregnancies that may necessitate a cesarean delivery to protect both her and her fetus. By conducting a thorough informed consent discussion in advance (an example of preventive ethics), the physician has the opportunity to explain the indications for an emergency cesarean delivery and review the risks and benefits in an unhurried, unpressured atmosphere. Routine prenatal care visits present an ideal setting in which to initiate discussion of potential pregnancy complications and prevent future misunderstanding and disagreement. The informed consent process should include a clear description of the specific circumstances in which cesarean section would be indicated, as well as a general overview of cesarean section as the patient gets closer to delivery. The physician can then directly address the patient's specific reservations about cesarean delivery and take time to answer any questions she may have. (Choices A and E) These responses are paternalistic, dismissing the patient's request and asking her to trust the physician without conducting an informed consent discussion. Instead, the patient should be empowered to make a fully informed decision by being educated about risks and benefits of vaginal versus cesarean delivery in specific situations. (Choices B and D) It would be premature to refer the patient to another provider or to merely document the patient's decision without first discussing the indications for cesarean delivery and addressing the patient's specific reservations. The physician may be able to resolve the patient's concerns so there is agreement about when a cesarean delivery is necessary. Educational objective: Routine prenatal care should include an informed consent discussion that anticipates clinical complications that may necessitate a cesarean delivery. This process should include a clear description of indications, risks, and benefits and an opportunity to address the patient's specific concerns and questions. References: Ethical dimensions of the fetus as a patient. (http://www.ncbi.nlm.nih.gov/pubmed/28190695)

A 29-Year-Old Primigravida at 36 Weeks Gestation Comes to the Office