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INTRODUCTION

Pregnancy is a period of social, physiologic, hormonal, and psychological change that affects all aspects of a woman's life. These changes, especially when accompanied by overlying preexisting risk factors for psychiatric illness, are all triggers for a first episode, recurrence, or worsening of a behavioral or mental health problem. The data on the management and treatment of psychiatric disorders in pregnancy is both highly variable and highly controversial. A large population–based study of pregnant women in Sweden reported that the point-prevalence of any psychiatric diagnosis was 14.1%, and in the United States, it is likely higher and, data suggests, continuing to rise.1

Gaps in the healthcare system regarding adequate prevention and intervention for women with mood/anxiety disturbances in the perinatal period have shown to have devastating emotional and medical consequences. Perinatal psychiatric disorders are a leading cause of maternal morbidity and mortality, with suicide in particular being the leading cause of maternal death. Lack of adequate guidelines, research, knowledge, proper counseling, medication management, and social prejudice related to the topic are a few of the problems that contribute to this rising and disabling group of illnesses. This chapter outlines the most acute and highest-yield preventative measures that can present to and be taken by the hospitalist during the perinatal period.

DECISIONAL CAPACITY DURING THE PERINATAL PERIOD

KEY QUESTIONS

  • How is capacity assessed in the labor and delivery (L&D) setting?

  • How should one take proper consent of a pregnant altered patient?

  • How should one assess and document capacity?

The matters of capacity and informed consent are among the most common reasons for psychiatric consultation in the perinatal inpatient setting. This is sometimes because the matter of decisional capacity was not addressed in the outpatient setting, but more often because women afflicted with illness that leads to impaired capacity often present emergently to the inpatient unit without having a history of healthcare taken. It is also easy for clinicians to assume that a patient is demonstrating the capacity for decision-making when she is consenting to management; only when she does not comply is her capacity called into question. There are many medical causes of altered mental status that can lead to the question of capacity, but this chapter will address only the most common cause in healthy, reproductive-age women: underlying chronic psychiatric pathology, acute intoxication, or both. It will also focus on determining capacity when a physician is confronted with a patient with signs of impaired capacity or a surrogate decision-maker, and a decision needs to be made either urgently or emergently.

Any physician can perform and document a capacity assessment; it does not have to be a psychiatrist. In fact, the physician responsible for performing any particular medical intervention is the best equipped to determine if the patient is able to demonstrate capacity to consent to that particular intervention. Documentation should include a review of the ...

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