​​A patient admitted to the labor and delivery suite was diagnosed with pre-eclampsia.  Her clinical status was deteriorating quickly, yet standard treatment options were challenging due to complicating factors.  The patient, transferred from a midwife service, was now refusing medications, epidural pain relief, and surgical delivery, even at the risk of harming her child. This patient’s “irrational” behavior prompted requests for emergency consultation with social services, psychiatry, the ethics committee, and the hospital’s legal department.

She had no other medical or psychiatric history that would explain her current behavior, except for a mention of “possible abuse” in her past.  No one had attempted to elucidate the reason behind her fear of a cesarean section.

There are so many implications for this scenario:

• Possible harm to life for herself and her child
• Extensive utilization of resources (all the consultations)
• Calls into question the legal rights of this mom- do fetal rights trump maternal rights?
• The majority of providers are ill-equipped to identify the risks, signs and symptoms of psychological disease processes

Soon after I arrived on the floor, she agreed to an epidural.  I chose to do this personally (and not have any trainees involved) because of my suspicion that her behavior was related to prior trauma.   During the epidural process, I empowered her to “be in charge” of the procedure by informing me when she might need me to pause for a contraction or any other discomfort she had. Once she was comfortable enough to talk through her contractions, I sat down on the couch next to her and inquired about why she really disliked the idea of going to the operating room. We had a meaningful conversation and elucidated issues that were directly responsible for her current behavior.  When I shared with her some of the things I can offer to anyone “who has had a bad experience in the past” she immediately answered “you can do that?” I mentioned to her that everyone “comes to us from a different background, with different fears” and has different needs.

        Although the source of our patient’s prior trauma was not revealed in detail, it was clear through our discussions that her extreme fear of surgery was rooted in her childhood sexual trauma, and the fact that she had been “re-victimized” during two prior orthopedic surgeries in which she remembers being “strapped down” and having an oxygen mask that “suffocated her”.   Ultimately, it was recommended for the physical safety of both her and her child that she receive a cesarean section. With a mutually agreed-upon plan in place, she consented (willingly) to surgery.

Our Plan: 

• She had her significant other in the room the entire time
• The arm boards were removed from the operating room table and she kept her arms on her chest throughout the case ( monitors were placed to accommodate this request)
• She received small doses of midazolam upon her request
• She had no face mask. 

    She enjoyed “skin-to-skin” bonding with her baby, and she was tremendously grateful for what we helped her to do.  

        The recognition of what others referred to as “irrational behavior” was actually understandable behavior if understood in the context of her trauma history.  Utilizing trauma informed care approaches, we did not need the services of the psychiatric, ethics, or legal team during her visit, however, I do believe social services did stop to visit with her.  She and her baby were physically healthy at the time of discharge and her psychological state was stable. 

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