Challenging Office Cases in Obstetrics and Gynecology Botros RMB Rizk, Martin E Olsen
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Refusal of Cesarean SectionChapter 1

Sheila A Connery
 
INTRODUCTION
The decision made by an expectant mother to refuse a recommended cesarean section is a real yet thankfully rare occurrence that obstetrical providers may face. Catastrophic consequences for both fetus and mother may result from this action. The manner in which a provider handles the situation undoubtedly influences the outcome.
 
CHARACTERISTICS OF WOMEN WHO REFUSE CESAREAN DELIVERY
A study conducted in the United States (US) involving women who rejected a cesarean section noted that 81% were black, Hispanic or Asian, 44% were unmarried, 24% did not speak English as their first language, and 100% were treated in a teaching hospital clinic or were receiving public assistance.1-3 Factors responsible for their decision included: fear of postoperative pain; 2harm and death for both mother and fetus; concern of cost and hospital fees; desire to avoid repeat cesarean deliveries; cultural or religious beliefs; and a lack of understanding regarding the gravity of the situation.1-3 Other reasons for refusal include an unwanted child and psychiatric disorders.2
In many third world nations, it is widely recognized that the morbidity and mortality after a surgical procedure is significant. This leads some patients from those areas to fear for their lives and thus decline an obstetrical provider’s recommendation.2 Hospital charges for cesarean sections typically exceed those for a vaginal delivery due to the use of an operating room with additional equipment, personnel, and pharmaceuticals along with potentially increased length of stay. Regarding vaginal birth after cesarean section, statistics suggest that the projected success of a vaginal delivery after cesarean section approaches up to 80% for appropriately selected candidates.1,3 This information may be misinterpreted by some women desiring vaginal delivery leading to an unrealistic expectation for success thereby refusing cesarean delivery. Mistrust of the medical system because of a past experience as well as concern for future obstetric capabilities also contribute to a woman’s propensity to decline an operative delivery.4 Finally, women originating from many Arab cultures may perceive a cesarean section as a form of mutilation thereby refusing the procedure.1,5
In Israel, it has been observed that the incidence of refusal for a cesarean section is directly proportional to increased parity. Pregnancy and labor complications for these patients were higher including placental abruption, preterm delivery and postpartum hemorrhage; along with a greater number of newborns had an Apgar score less than 7 in one and five minutes. In addition, an increased incidence of intrapartum fetal death and overall perinatal mortality was also noted.6
 
BACKGROUND OF PATIENTS WHO REFUSE SURGERY
The American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics issued a committee opinion entitled: Maternal Decision Making, Ethics and the Law, which traces the origins prompting refusal of cesarean sections. Prior to the 1970s, the well-being of the mother consistently took precedence over the outcome of the fetus. This philosophy was generally accepted by the family, physicians and nurses caring for the mother. With the development of techniques in the seventies that provided imaging, testing and the capability for treating fetuses, the dilemma prompting refusal for cesarean section was born.7 A framework was created because of these advancements which viewed the fetus as an independent patient. Some women chose not to recognize this new framework.
Bioethical models described by Tauer perceive the mother and fetus as either a one or two patient concept. In a one-patient model, the pregnant woman and her fetus are viewed as an organic whole which balances prospective benefits of the fetus with possible harm to the mother.8 This 3concept differs from a two-patient model where mother and fetus are seen as two distinct individuals with greater focus on fetal well-being since a fetus is seen as a distinct individual.8
Beginning in the early 1980s in the US and 1992 in the United Kingdom (UK) these new considerations coincided with physicians or hospital officials seeking forced or court ordered cesareans on competent women when they refused the procedure.9 Court orders were sought that authorized physicians to perform a cesarean section against the patient’s will. In the US, most cases occurred during a patient’s labor and involved a judge who heard only the doctors or administrator’s version prior to issuing the court order.9
In 1997, the court of appeals in both countries stated that the doctrine of informed consent applied to pregnant women even if the decision to refuse a cesarean section endangered the mother’s life (such as in placenta previa).9 An obstetrical provider, currently, still has the ability to seek a court order if a woman refuses a cesarean delivery.
 
INTERNATIONAL MANAGEMENT OF WOMEN WHO REFUSE CESAREAN DELIVERY
As of 1998, UK law does not grant a fetus any legal status; this comes only after the moment of birth.2 Likewise a Committee Opinion of ACOG in January 2004 issued a statement concerning the management of cases involving maternal refusal of treatment for the sake of the fetus. The committee stated, “court ordered intervention against the wishes of a pregnant woman is rarely if ever acceptable.”7,10 It remains the obligation of the obstetrician to clearly convey the reasoning behind the recommendation for cesarean section to the patient as well as to examine the barriers to consenting for the procedure along with her, and to encourage the development of health-promoting behavior.7,10 It must be conveyed to patients that medicine is an imprecise science and has its limitations in its ability to predict outcomes. ACOG supports the notion that an obstetrician must respect the patient’s autonomy and therefore should not intervene against her wishes regardless of the consequences.7,10
There is no legal penalty placed on a physician in the US for failure to seek a court order when a patient has knowingly exposed her fetus to a risk of harm.1 A woman has the constitutional right to refuse any medical procedure. Performing a surgery without her consent could be considered assault and battery.1
Sweden, in addition to the US and UK, has no law that enforces a recommendation from caregivers because the autonomy of the woman gives her the right of refusal in that country.11 Sweden like the US and UK, grants the fetus no legal status until it is born and shows signs of life.11
Obstetricians from various European countries were polled as to their attitudes towards women who refused a recommended cesarean delivery. It was noted that most responders from the UK, Sweden and the Netherlands would accept a woman’s refusal to undergo a cesarean section in contrast 4to those responders from Spain, France, and Italy and to a lesser extent Germany and Luxembourg who would seek a court order on behalf of the fetus or to avoid legal liability or both.12 The difference in opinion among responders depends on the legal status of the fetus in that country. Physicians from countries such as UK and Sweden are willing to comply with the maternal autonomous decision since a fetus has no legal status there while obstetricians from Italy, Spain and France are less likely to comply with the woman’s decision because in France, opinions lean more to beneficence and in Italy the fetus is assumed to have the same rights as a neonate.12
An article published from Norway concluded that in an emergency situation a physician has the right to perform a cesarean section without the woman’s consent in an effort to save a fetus from death or major injury.2 An acknowledgement was made that the woman’s autonomy would be violated yet justified the obstetrician actions who considered ‘the weakest right’ and the ‘greatest health benefit’.2
 
AMERICAN CONGRESS OF OBSTETRICS AND GYNECOLOGY (ACOG) RECOMMENDATIONS
Despite the differences in management in Europe and the US, a Committee Opinion was made by ACOG issuing a set of recommendations for obstetricians faced with a patient who refuses a cesarean section in November 2005.
  1. Maintenance of a good physician-patient relationship is always in the best interests of both woman and fetus even when the interests of the pregnant woman and her fetus diverge rather than converge.
  2. A pregnant woman’s autonomous decision should be respected. Rarely is there ever an indication to implement judicial authority in order to carry out treatment plans to protect the fetus.
  3. Pregnant women should not be punished for adverse perinatal outcomes. The relationship between maternal behavior and perinatal outcomes is not fully understood and punitive approaches threaten to dissuade pregnant women from seeking health care and ultimately undermine the health of pregnant women and their fetuses.7
Pregnant patients in America are delivered via cesarean section for a multitude of reasons. Women undergoing major abdominal surgery agree to this procedure in an effort to maximize the healthy outcome of their baby even though there is no direct health benefits to the mother in most cases.13
The following plan is for patients that are competent. Generally, a patient is presumed competent unless she has been legally deemed incompetent. For those patients receiving antenatal care that inform their provider of their intention to refuse a cesarean delivery the following proposal should be considered prior to the outset of labor in an effort to avert a horrific situation. First, establish a conference separate from office hours where the patient and her family along with all of the obstetrical providers involved can enter 5into a discussion in a non-emergent setting. Second, time should be allotted whereby the providers can present a rationale for the recommended cesarean section along with potential risks to the patient and fetus for refusing with the possibility for maternal and/or fetal death specifically mentioned. Risks of the procedure itself should also be mentioned. Thirdly, the patient and family should be encouraged to discuss their reasoning behind the refusal with the intention of assisting the patient through a safe delivery process for herself and her fetus, particularly if the underlying cause can be easily addressed (finances, fear, etc.). Fourth, every effort should be made to arrange consultations with a NICU team, social services and pastoral support as well. These principles were developed by Tampa General Hospital Tampa, Florida as a policies and procedures directive for patients refusing cesarean delivery.14
In the event that the patient remains convinced that she will refuse a cesarean section when admitted to Labor and Delivery, a form located on many Obstetrical Units such as Tampa General Hospital called a Release of Liability for Refusal to Consent to a Recommended Obstetrical Plan of Care and Procedures should be presented to the patient for signature.
The form acknowledges that the obstetrical providers follow obstetrical standard of care including in this case interventions for a safe and timely delivery of infants including a cesarean section. The providers strongly recommend that a cesarean section be performed with the reasons listed. The patient acknowledges that she had the opportunity to discuss this recommendation with the medical team and all of the patient’s questions concerning the recommended cesarean delivery have been answered. The patient acknowledges she does not agree with the recommendation which is the standard of care and that the consequences may include, but are not limited to uterine rupture which may cause severe and permanent effects including death along with lack of oxygen to a fetus which may cause severe and permanent effects including brain damage and death. The patient signs the form stating she is refusing the cesarean section and that she has read the document in its entirety and fully understands.14
The hospital where the patient intends to deliver her baby should be notified of the patient’s intentions and obtain their own Release of Liability for Refusal to Consent to Recommended Obstetrical Plan of Care and Procedures.
 
FINAL THOUGHTS
Refusal to undergo a recommended cesarean delivery is a unique dilemma for obstetrical providers and the entire health care team tending to the patient. With appropriate counseling in a non-emergent setting, the optimal outcome can hopefully be achieved for both the patient and her fetus. In the end, the mother’s decision must be followed except in rare circumstances.
6REFERENCES
  1. Deshpande NA, Oxford CM. Management of pregnant patients who refuse medically indicated cesarean delivery. Reviews in Obstet & Gynec. 2012; 5(3/4): e144–e150.
  1. Lyng K, Syse A, Bordahl P. Can cesarean section be performed without the woman’s consent? Acta Obstet Gynecol Scand. 2005; 84: 39–42.
  1. Curran WJ. Court-ordered cesarean sections receive judicial defeat. N Engl J Med. 1990; 16; 323:489–92.
  1. Ribak R, Harlev A, Ohel I, et al. Refusal of emergency caesarean delivery in cases of non-reassuring fetal heart rate is an independent risk factor for perinatal mortality. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2011; 158: 33–6.
  1. Lipson JG, Dibble SL, Minarik PA. Culture and Nursing Care: A Pocket Guide. San Francisco CA: University of California San Francisco; 1996.
  1. Iris O, Amalia L, Moshe M, et al. Refusal of treatment in obstetrics – A maternal- fetal conflict. The Journal of Maternal-Fetal and Neonatal Medicine. 2009; 22(7): 612–5.
  1. Maternal Decision Making, Ethics, and the Law. ACOG Committee Opinion. 2005; 321: 1–11.
  1. Tauer AC. Lives at stake. How to respond to a woman’s refusal of cesarean surgery when she risks losing her child or her life. Health Prog. 1992; 73(7): 18–27.
  1. Ikemoto L. Forced cesarean. Current Opinion in Obstetrics and Gynaecology. 1998; 10(6): 465–8.
  1. Patient choice in the maternal-fetal relationship. American College of Obstetricians and Gynecologists. Ethics in Obstetrics and Gynecology (2nd edn). Washington, DC: ACOG  2004; p.34–6.
  1. Danerek M, Marsal K, Cuttini M, et al. Attitudes of Midwives in Sweden Toward a Woman’s Refusal of an Emergency Cesarean Section or a Cesarean Section on Request. Birth. 2011; 38: 71–9.
  1. Cuttini M, Habiba M, Nilstun T, et al. Patient Refusal of Emergency Cesarean Delivery A Study of Obstetricians’ Attitudes in Europe. Obstet & Gynec. 2006; 108(5): 1121–9.
  1. Berkowtiz, R. Should Refusal to Undergo a Cesarean Delivery Be a Criminal Offense? American College of Obstetricians and Gynecologists Rights of Pregnant Women. 2004; 104(6): 1220–1.
  1. Tampa General Hospital Tampa, Florida Policies and Procedures Form for a pregnant patient refusing a treatment or procedure that in the Obstetrician’s opinion places the mother and/or fetus at risk of jeopardy. Release of Liability Form for Refusal to Consent to Recommended Obstetrical Plan of Care and Procedures 2014.