A 31-year-old woman, gravida 2 para 1, is brought to the emergency department by her husband due to heavy vaginal bleeding. She is at 30 weeks gestation by a last menstrual period and has not received prenatal care. The patient has had heavy vaginal bleeding for the past 2 hours, soaking through a pad every 30 minutes. Her last pregnancy ended in an uncomplicated term vaginal delivery at home. Vital signs and fetal heart rate tracing are normal. A transvaginal ultrasound reveals a complete placenta previa. After conservative management, the vaginal bleeding stops. The findings and management, including a cesarean delivery, are discussed with the patient and her husband. The patient says she does not want a cesarean delivery because she would like to deliver at home again. Which of the following is the most appropriate statement?
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Most medical decision-making considers the patient's preferences and values, which are then used to determine the best treatment option. However, when there is only 1 safe, reasonable treatment option with clearly superior evidence, physicians should perform directive counseling and assume an active role in guiding therapy.
This patient has a complete placenta previa, in which the entire cervical os is covered by the placenta. This completely obstructs fetal delivery and can lead to unexpected, often unprovoked, heavy vaginal bleeding. Although low-lying placentas and partial placenta previas may resolve with time (due to upward expansion of the lower uterine segment, which pulls the placenta toward the fundus), complete placenta previas are highly unlikely to resolve. Therefore, vaginal delivery is contraindicated due to imminent maternal (eg, hemorrhage) and fetal (eg, intrauterine demise) morbidity and mortality. The only safe option for delivery is cesarean delivery.
Currently this patient's bleeding has stopped; she is not in active labor; she does not require immediate delivery. When the time comes for delivery, the patient has the right to accept or refuse cesarean delivery (ie, patient autonomy takes precedence). However, it is still the physician's ethical duty to advise against vaginal delivery and provide directive counseling by explaining why cesarean delivery is medically necessary.
(Choices A and E) Patients have autonomy to make decisions against medical advice. However, even if the patient agrees to the risks of vaginal delivery, the physician cannot condone this life-threatening option (eg, "I will allow"). Endorsing half-measures (eg, "You can choose to have a vaginal delivery, but I recommend that you come to the hospital") is also misleading, and bargaining with the patient is inappropriate. The only ethical recommendation in this situation is cesarean delivery, and the physician should practice directive counseling with this patient.
(Choice C) Assisted decision-making, in which family members help make decisions, is not required in this situation because the patient's husband's preference for mode of delivery does not change the need for cesarean delivery.
(Choice D) The risk of repeat hemorrhage in patients with placenta previa is highest following an initial bleeding episode. Therefore, decision-making should not be delayed in case another life-threatening bleed occurs.
Educational objective:
When there is only 1 safe, reasonable treatment option, physicians should perform directive counseling and assume an active role in guiding therapy. Physicians should explain to patients with complete placenta previa that cesarean delivery is medically necessary.