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INTRODUCTION

KEY QUESTIONS

  1. What frameworks are helpful when navigating ethical dilemmas in OB/GYN?

  2. What is the impact of patient pain and anxiety on standards of informed consent?

  3. What precepts should be used to guide care during clinical emergencies?

  4. How should you approach a patient who declines recommended care that would be beneficial to either herself or her fetus/baby?

  5. What are the ethical challenges when patients present in labor or in need of delivery periviable gestations?

The field of obstetrics and gynecology (OB/GYN) presents some of the most challenging and poignant ethical dilemmas for healthcare providers, healthcare systems, and their patients. At the foundation of these dilemmas lie profound questions about the beginnings of human life, reproductive justice, and the nature and obligations of impending motherhood. For healthcare providers, these issues often translate into the practical questions of who is the patient (i.e. the pregnant woman, the fetus, or both) and how to balance our ethical obligations to the pregnant woman and fetus. These are difficult questions in the setting of routine prenatal care, often intensified in the acute setting of the labor floor.

Pregnancy is also not a static condition: the progression of the pregnancy from trimester to trimester alters both what medical options are reasonable to offer patients and the counterbalancing risks that a pregnant woman may have to sustain. For example, it may be reasonable to offer a chorionic villus sample to a woman at 10 weeks gestation, with an associated risk of miscarriage of 1%. That same risk of fetal loss, however, may seem unacceptable at a later gestational age, especially after a fetus approaches or has reached viability. As pregnancies approach term, the benefits to the fetus of remaining in utero and the risks to the woman of remaining pregnant run in opposite directions.

The growth of the hospitalist model of care has added to some of these challenges as the delivering or inpatient healthcare provider may not be the one with whom the patient has an established relationship. Concomitantly, women with more severe morbidities are now able to achieve pregnancy. Thus patients who are more likely to have complicated medical courses—and therefore more likely to engender ethical dilemmas—are being cared for more and more frequently by providers to whom they have less of an established physician-patient relationship (or none at all). The goal of this chapter is to provide a framework to help resolve some of the ethical dilemmas that might arise on the labor floor and to demonstrate ethical analysis using this framework with a series of illustrative cases.

THE MATERNAL-FETAL DYAD

One of the first steps in approaching ethical issues in obstetrics is to establish a framework for understanding and describing the state of pregnancy. One such concept is the maternal-fetal dyad, which describes the interconnected state and changing relationship between the pregnant woman and the fetus over the course ...

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