Question

Case Study: Pamela

Pamela is 27 years old and pregnant for the first time. She is in excellent health, is a marathon runner and works as legislative aide in State Assembly. She began her prenatal care with ob-gyn practice where she had received her well-woman care for the past 3 years. She liked the doctors very much and kept all of her appointments. She and her husband Ramon were thrilled to see their baby on ultrasound and Pamela was looking forward to her childbirth classes and an uneventful birth.

During her childbirth classes she learned about fetal monitors, medical management of labor which often included intravenous fluids and sometimes induction or augmentation of labor with oxytocin. Pamela didn’t want any of these things nor did she want an epidural for pain relief and was dismayed to learn that over 80% of the patients who deliver at the hospital in her community have an epidural for labor. The final straw was when she and Ramon took a tour of the hospital birthing center and discovered that the cesarean section rate was over 30%. At 32 weeks, Pamela knew she had few options for obstetric care but friends of hers told her about a group of women who did “home births.” While not certified midwives, these women were experienced and Pamela was eager to meet them. Ramon was a bit concerned but said that Pamela was the one going through labor and he would abide by her decision.

Pamela elects to deliver at home with these birth attendants and when she begins to notice contractions a few weeks later, she calls the birth attendants who arrive at her home and begin preparations for the birth. Pamela is not quite 37 weeks yet. The birth attendants examine her and tell Pamela that she is 2 cm dilated and almost 100% effaced. Pamela’s labor has begun. Over the next few hours, Pamela breathes through her contractions which are increasing in intensity and frequency. She moves about freely and sips on some tea with honey and lemon. Ramon remains by her side. About six hours into her labor, Pamela is tired and wants to rest but the contractions are now every 2 minutes and strong. She finds herself increasingly anxious and irritable and demands that the birth attendants check her to see if any progress is being made.

The attendant does an exam which reveals that she is now 4-5 cm dilated but surprisingly they also discover that she is breech. At this point the birth attendant goes to the phone and consults a midwife friend who suggests that they get Pamela to a hospital as soon as possible. Pamela and Ramon are heartbroken and do not want to go however the birth attendant tells them that she has never delivered a breech before and does not know what to do. Reluctantly Pamela is transported to the hospital where she is immediately placed on a fetal monitor, blood work is drawn and an IV is inserted in her arm. Unbeknownst to Pamela and her husband, the staff are setting up to do a cesarean section.

The attending obstetrician arrives and re-examines Pamela. She is now nearly 8 cm dilated and he recommends an emergency cesarean section telling her it would be very dangerous to her and especially to her baby if she tried to deliver vaginally. He tries to explain why he believes this to be true but Pamela feels a strong urge to push and the conversation abruptly ends. Pamela screams at Ramon and the doctor that she will not have a cesarean section. Both Ramon and the doctor try to reason with her but she is adamant. The nurse then notices that the baby’s heartbeat is slowing down to a dangerous rate and the doctor orders that Pamela be taken to the operating room immediately.

With Pamela still begging to deliver vaginally, she is given general anesthesia and her baby boy is born 12 minutes later by cesarean section. Though a little bit slow at birth, the baby has an Apgar score (Links to an external site.) of 9 at 5 minutes and is given to Ramon to hold in the recovery room. Pamela wakes up with a sharp pain in her abdomen and the nurse quickly shows her how to use the patient controlled analgesia. In a medicated haze, Pamela sees her newborn for a few minutes before he is brought to the nursery and put under heat to bring his temperature up.

Now let’s go through the discussion questions one by one.

1. Do you believe the actions of the hospital staff and the doctor were ethically justified? Support your answer with the principles and theories we have learned.
2. What were the ethical obligations of Pamela and Ramon? Did they behave ethically? Why or why not?
3. Finally, do you believe that there should be a law outlining the conditions under which a woman’s right to choose how and where she gives birth can be over-ridden for the safety of her unborn child? Why or why not?

Answer 1

1. The actions of the hospital staff can be justified, as their primary aim was to save the lives of the mother as well as the baby.

The breech delivery can be complicated, and in the middle of delivery, if the fetal compromise occurs, that might have affected the life or the health of the fetus in a very adverse manner. So it is the health care worker's responsibility to save the fetus live and healthy.

Importantly they shifted her to OR, when the fetal heart rate went down dangerously low.

Also getting ready for the Caesarian section, without the couple's knowledge , can not be fully justified. The couple must be informed of the complications of a breech delivery and how it may affect the health of the baby.

A clear teaching might have helped Pamela understand the situations and being supportive, as no parents want their to be born child's life to be in danger.

Also she might be scared of CS and its issues. A quick teaching on how and what it is could have made her a bit more comfortable.

2. Pamela has all the right to opt for vaginal delivery, because labor is a normal process . But since the baby is in breech position, and the doctor and staffs are not supporting a vaginal delivery due to health concern, it is their duty to oblige to them. Their primary concern must be the healthy baby and mother.

Ramon was supportive as the doctor told its an emergency CS. But Pamela objected and wanted to push out the baby. May be she could do that. But if she could not do that, there arises a very critical situation and it may endanger the life of the baby sometimes. So the lady remained adamant on her right to deliver vaginally and it doesn't match the situational ethics.

3. Yes. I believe there should be law to protect the baby in such situations as these situations are not rare in a clinician's life.

The medical care and technology has progressed to a great extent and even now we are losing new borns because of lack timely management , is a shame to the profession. So if a law can protect the baby and its health, that must be done. The law to over ride the right of a mother to choose how and where she gives birth can be overridden for the safety of unborn child.