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 that would 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 may 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?
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 for conversations addressing planned and potentially unanticipated delivery situations and necessary interventions (eg, emergency cesarean delivery); such conversations serve to optimize shared decision-making and prevent future misunderstanding and disagreement. When reviewing potential treatment needs in advance, the informed consent process should include a clear description of the specific circumstances in which a cesarean delivery would be indicated, in addition to a comprehensive overview of how a cesarean delivery is performed. This allows the physician to 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 shut down the conversation based on the physician's preferences while dismissing the patient's own concerns and rationale for her objections; they also threaten her with abandonment or a potential procedure against her will. In contrast, the process of shared decision-making respects the patient's values and priorities and would more effectively open her to receiving education on vaginal versus contingent cesarean delivery.
(Choices B and D) While it is important to recognize patient autonomy, the physician may be able to address the patient's concerns to reach agreement about when a potentially life-saving cesarean delivery would be acceptable to her. Therefore, it is premature to merely document a decision without first understanding the patient's reservations, providing adequate education relevant for the decision-making process, and specifically discussing the indications for cesarean delivery.
Educational objective:
Routine prenatal care should include an informed consent discussion that anticipates clinical complications necessitating a cesarean delivery. This process should include a clear description of indications, risks, and benefits as well as an opportunity to address the patient's specific concerns and questions.