New guidelines for intrapartum management of patients with mental disorders

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1. This research paper proposes a preventive six-step ethics algorithm to guide intrapartum management of patients with major mental disorders. 

2. Multiple attempts should be made to obtain active assent such that every attempt is made to avoid coerced clinical management, the final option in the algorithm. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Because women in labor with major mental disorders may have impaired decision-making abilities, women in this population pose a unique challenge when decisions often need to be made quickly. This paper provides a systematic framework to guide physicians in a way that navigates the difficult balance between patient well being with autonomy.

No previous guidelines exist and authors suggest that providing such guidelines might reduce treatment bias, strengthen physician integrity and reduce liability since physicians can refer to use of a framework that is both clinically guided and ethically sound.

Click to read the study in the American Journal of Obstetrics & Gynecology

Relevant Reading: American College of Obstetricians and Gynecologists: Maternal decision making, ethics, and the law

In-Depth [clinical guideline]: This study proposes a six-step ethics algorithm for approaching intrapartum management of patients with major mental disorders:

1. Capacity: The patient’s capacity to consent should be evaluated.

2. Attempt to restore capacity: If impaired, attempts should be made to restore it through verbal prompts, appeals to her values and/or pharmacologic interventions provided there is time.

3. Substituted judgment: If previous attempts are unsuccessful, decisions need to be made by a surrogate and should be informed first by the patient’s preferences and second by the mother and infant’s best interests.

4. Determine if patient accepts treatment.
5. Last opportunity for active assent: If patient refuses treatment at step 4, a final attempt should be made to obtain patient assent through verbal and/or pharmacologic means. In the event that this fails, then the physician’s beneficience-related duty to the woman and her child overrides his or her need to respect patient autonomy, and coerced clinical management is the least worst option.

6. Coerced clinical management: to be used only after steps 1-5 fail.

Strengths of this framework include incorporation of literature on maternal-fetal medical ethics. Limitations include lack of evaluation of the use of this algorithm in a practical setting. Future studies might assess the use of this framework in relation to maternal and fetal outcomes, as well as maternal satisfaction with intrapartum care management.

By Denise Pong and Leah Hawkins, MD, MPH

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