Last week, one of my midwife partners called to tell me about a patient — Ms. U —who had presented to labor and delivery at our hospital. Ms. U, was not a patient of our practice, nor was she a patient of our clinic or any other private physician at our hospital. A primigravida at 39 weeks gestation, Ms. U claimed she was “stopping by” labor and delivery on the advice of her midwife to have us “check on the baby.”
Upon further investigation, it was determined that Ms. U had been discharged from three local obstetric practices during her pregnancy due to noncompliance, and had received no recent prenatal care. Upon assessment, Ms. U was diagnosed with severe preeclampsia and advised that she should be admitted, have her labor induced and be administered IV magnesium sulfate therapy to prevent eclampsia.
Ms. U refused all intervention and left the hospital against medical advice, signing a document acknowledging all the possible risks to herself and her unborn child, including death. Before leaving, Ms. U explained to the nurses that her instinct was that her baby was fine, that she did not believe she would have a seizure, and that labor would start when it was time. She felt strongly about not receiving any type of intervention, despite the very real dangers of placental abruption and eclampsia, among other risks.
I usually tend to be biased toward nonintervention. I believe that pregnancy is not a disease to be managed. I prefer to let labor start on it’s own, to leave the amniotic membranes intact, and to give a laboring mother time to progress on her own, rather than according to a preset labor curve. One intervention tends to lead to another intervention, and it can be a slippery slope right towards an unnecessary cesarean section.
But there are times, such as Ms. U’s case, that intervention is without a doubt the safest and wisest plan of action. Certainly, no one plans on developing preeclampsia, gestational diabetes or experiencing any of the complications possible in the course of pregnancy, labor and birth. However these problems do arise, and all obstetric care providers from homebirth midwives to hospital obstetricians are trained to recognize and manage these special circumstances accordingly.
Sometimes the cost of being rigidly against any intervention is too great. Although I understand Ms. U’s skeptical view on routine intervention during a healthy pregnancy, I worry that she is putting herself and her baby in true danger.
Ms. U’s pregnancy is medically complicated and should be closely observed, preferably with her admitted to inpatient care. I worry that the next time this patient arrives on our labor and delivery unit, it will be too late to intervene.
Have you experienced similarly difficult patients in your practice that posed a threat to their own health because of noncompliance? What did you do?
Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.