Strategies to Help You Avoid Dismissing Pregnant Patients

Pregnancy can be a time filled with a multitude of emotions and strong desires regarding how a patient envisions their pregnancy and birth experience. Like all providers, OBGYNs may occasionally come to realize that they have a physician-patient relationship with an individual who may have deep beliefs, opinions, or desires that are in opposition to the physician’s medical judgment.

In some cases, the physician may wish to discontinue providing care if the patient will not follow the physician’s treatment recommendations or if the physician is not comfortable with the patient’s birth plan. However, if you find yourself in that situation, consider that terminating the relationship during pregnancy may have ethical, legal, and logistical complexities that are unique to OBGYNs. This article discusses how you might minimize such situations in your practice, and how to move forward even if you are not able to preempt them. 

Shared Decision-Making: Communication and Informed Consent 

One way to foster positive relationships with pregnant patients is to understand how to engage in shared decision-making with your patients at their first appointment through their last postpartum appointment. Shared decision-making is a patient centered approach that is considerate of the patient’s values, preferences, and priorities while ensuring they are making fully educated decisions about their care and treatment during pregnancy, delivery, and postpartum.

Essentially, “[s]hared decision making is a patient-centered, individualized approach to the informed consent process that involves discussion of the benefits and risks of available treatment options in the context of a patient's values and priorities.”¹  Understanding the patient’s reproductive desires is crucial to having a productive informed consent conversation, and the American College of Obstetrics and Gynecology (ACOG) is clear in its stance that patient autonomy should be respected, even when the physician’s own values, priorities and culture do not align with the patient’s. 

Pregnant patients have the right to make decisions about their own healthcare, including refusing treatment, but you may struggle to accept those choices if they conflict with your medical judgment or personal values. Engaging in shared decision-making may help you understand the patient’s mindset on a deeper level and have a productive conversation that leads to a meeting of the minds. Doing so may also help you determine early in the patient’s pregnancy if you are a good fit, so that there is less likelihood of finding yourself in a difficult position if your medical judgment is not aligned with the patient’s desires for their pregnancy and delivery, or the patient has a request or demand with which you are uncomfortable or are unable to fulfill. 

Consider the following real-life examples of times when engaging in shared decision-making early in the physician-patient relationship may have led to greater understanding of the patient’s values and priorities, and could have informed the care plan moving forward. 

Case Study: Patient’s Religious Beliefs Inform Their Birth Plan 

Jill is pregnant with her first child and, at the beginning of her pregnancy, asked her friends for OBGYN recommendations. Two couples with whom she and her husband are close recommended Dr. Hughes because of her warm bedside manner, calm demeanor especially in stressful moments, and genuine care for her patients. Jill and Dr. Hughes immediately clicked at Jill’s first appointment and she was happy to be in the care of someone so competent and kind. Her pregnancy progressed uncomplicated, and she followed Dr. Hughes’ advice for all prenatal care and testing.  

At Jill’s 36-week appointment with Dr. Hughes, her husband joined her as he had a few other times. Dr. Hughes advised the couple that they should decide which hospital to go to for delivery so that they have the route mapped out and know how to get to Labor and Delivery once there. Jill’s husband responded that they would go to the non-teaching hospital where Dr. Hughes has privileges because they did not want to chance a male resident being involved in the delivery. Dr. Hughes was immediately concerned. She explained to the couple that she was not aware they did not want a male physician delivering the baby and that because her on-call group includes a few male doctors, there was a chance their request could not be honored.  

Jill’s husband was frustrated by this news and explained that it was not simply a request, but that their religious beliefs dictate that only a female provider deliver their child. Dr. Hughes did her best to calm the couple but was at a loss for how to continue her otherwise healthy relationship with the patient when she knew she might not be the one to deliver the couple’s baby. 

Dr. Hughes called the Risk Team seeking advice. They talked through whether patient dismissal and transfer to another provider was possible and appropriate at this late stage, and if there was any way to honor the patient’s wishes because she was so close to delivery, even though it might be out of the normal course of Dr. Hughes’ practice to ensure she would be the one to deliver.

After addressing the acute issue, Dr. Hughes and the Risk Team discussed how this situation could have been avoided. Dr. Hughes recognized that she should be asking about religious beliefs that might inform a patient’s birth plan from the very beginning and documenting those conversations. She should also let all patients know that because labor is unpredictable, she has partners who cover call at different times and one of those doctors might deliver their child.  

Delving into her patient’s background and beliefs while setting expectations for how her practice operates might have avoided the situation, even if it meant the patient moved on to another practice early in pregnancy when such a transition is easier to make. 

Case Study: Patient Wants to Attempt a VBAC 

Sandra is a mother of two and currently pregnant with her third child. Both of her prior deliveries were by C-section. Sandra established care with Dr. Hughes when she was 12 weeks along in her current pregnancy. At one of her first prenatal appointments, Sandra expressed a desire to experience natural labor, but it seemed like she had resigned herself to another C-section because of the risks associated with VBAC.  

Sandra continued to see Dr. Hughes for prenatal appointments and followed all of her treatment and testing recommendations. Sandra and Dr. Hughes did not discuss VBAC again until Sandra’s 32-week appointment. Sandra had been researching TOLAC and VBAC and was convinced that she was a good candidate. She was not going to accept any alternative because she so strongly desired to give birth “as nature intended.” This shift in Sandra’s demeanor concerned Dr. Hughes because Sandra’s blood pressure had been steadily increasing over the past few visits.

At her 34-week appointment, Sandra was directed to go to the hospital for blood pressure monitoring because it was too high in the office. Sandra was discharged with additional care instructions and followed up with Dr. Hughes the next day. Dr. Hughes counseled Sandra on the dangers of high blood pressure and told her that she was not comfortable moving forward with a VBAC. Dr. Hughes felt that scheduling a C-section was the best course of action. 

When Sandra refused to schedule the C-section, Dr. Hughes called the Risk Team who suggested that she bring Sandra into the office for further discussion. The Risk Team recommended that:

• Dr. Hughes express her understanding that Sandra wanted to have a natural birth experience. 
  
  
• Dr. Hughes review Sandra’s research with her and present her own evidence-based clinical opinions of why it would be dangerous to attempt a VBAC given Sandra’s high blood pressure. 
  
  
• Thoroughly discuss the risks and benefits of TOLAC and VBAC given Sandra’s condition. 
  
  
• Allow Sandra time to process the information and ask questions.
  
  
• If Sandra still refuses to schedule a C-section, Dr. Hughes should express that though she does not agree, she will respect Sandra’s wishes and ask Sandra to sign an informed refusal document.
  
  
• Let Sandra know the circumstances in which a C-section may still be required if she chooses to wait for labor to start naturally. 

The Risk Team also advised that this conversation should be thoroughly documented in the patient’s medical record and copies of all written materials provided to Sandra also kept in the record. 

Taking time to thoroughly discuss the situations in which a TOLAC and VBAC might be appropriate, the situations in which it would be dangerous, and any other risks, benefits, and alternatives with Sandra when she expressed her desire to experience a natural birth at the beginning of her pregnancy may have helped avoid this difficult situation.  

Transferring Care of Pregnant Patients 

Transferring care of a pregnant patient to another OB should be a rare occurrence. The risk of patient abandonment is higher among pregnant patients because there could be a gap in care during which the patient suffers harm because she and her baby are not being monitored at the recommended intervals. This is especially true the farther along a patient is in pregnancy and of complicated pregnancies. 

If a pregnant patient chooses to transfer care on their own, or it becomes clear that there are circumstances under which you are truly unable to continue providing prenatal, delivery, and postpartum care, consider the following: 

• Discuss with the patient the importance of selecting a new OB and continuing to seek prenatal care at the recommended intervals. 
  
  
• Ask the patient to tell you who they have chosen as a new OB so that you can send records and call the office to ensure that the patient has established care. 
  
  
• Answer any questions the new OB has about the patient’s condition and treatment. 
  
  
• Continue to contact the patient and/or their new OB until you are satisfied that the patient is receiving care. 
  
  
• Document your efforts in the patient’s record and, as a general rule, continue providing care at the necessary intervals until the patient is established with a new OB. 
  
  

Caring for patients throughout their pregnancy, delivery, and postpartum period involves unique considerations when physicians are faced with circumstances, requests, or demands that go against their own practice philosophy, clinical judgment, or are simply logistically difficult to accommodate.

If you have additional questions or would like to discuss a situation further, the Risk Team at MICA is here to help Monday-Friday, 8am-5pm at 800-352-0402 x 2137, 602-808-2137, or rm_info@micainsurance.com.

^{[1] Informed Consent and Shared Decision Making in Obstetrics and Gynecology | ACOG}