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Insanity on the Labor Unit: Schizophrenia and Ethical Dilemas
Abstract Number: F-80
Abstract Type: Case Report/Case Series
Our goal is to present a case that poses interesting ethical issues in the practice of medicine and obstetrical anesthesiology in particular. Globally there has been much written about the responsible care of pregnant patients with major mental disorders. The ethical dilemmas include 4 components: the concept of the fetus as a patient, the definition of maternal decision-making capacity, the concept of maternal assent, and beneficence-based clinical judgement.
The patient was a 35 year old woman who was gravida 6, para 5005. All her off spring resided in foster care. She presented to our institution at 39 weeks estimated gestational age as a transfer from a psychiatric hospital. She carried a long-standing diagnosis of paranoid schizophrenia with a history of violent tendencies towards healthcare workers, as well as incarceration for assault. She had been transferred for possible vaginal bleeding and refused any form of examination pre-transfer. She had been involuntarily committed earlier in her pregnancy and it was determined that she was confined to the hospital without the capacitance to leave against medical advice (AMA). Psychiatry deemed this patient to be lacking in capacity to make medical decisions for herself and the unborn fetus. After multiple failed attempts to reach relatives and close acquaintances, it was determined that the physicians would make decisions that were in her best interest. They stipulated that she could not refuse any necessary procedures during this period, such as vaginal exams and / or cesarean section for maternal or fetal indications. Appropriate care was taken to ensure the safety of this patient and hospital staff including removing potentially dangerous objects from the area, appointing a patient sitter, chemical restraints on stand by, and medical staff entering and examining the patient in pairs. As she progressed towards active labor, multidisciplinary discussions around the placement of a labor epidural occurred. As a labor epidural is generally regarded as an elective procedure, it was unclear if the guidelines set forth by psychiatry would cover this procedure. The patient had undergone epidural placement with prior pregnancies. Patient at this time requested a labor epidural for pain control. The anesthesiology team along with maternal fetal medicine determined that an epidural would be in her best interest. A full discussion of risks, benefits, and alternatives was had with the patient who appeared to fully understand these concepts, although a consent form was not formally signed. A labor epidural was placed without issue and the patient had an uneventful labor course resulting in a spontaneous vaginal delivery. Postpartum the baby was released to responsible foster parents and the patient was returned to inpatient psychiatric care.
1. Babbitt KE, et.al . Professionally responsible intrapartum management of patients with major mental disorders. Am J Obstet Gynecol. 2014 Jan;210(1):27-31