Pregnant women with major mental disorders present obstetricians with a range of clinical challenges, which are magnified when a psychotic or agitated patient presents in labor and there is limited time for decision making. This article provides the obstetrician with an algorithm to guide professionally responsible decision making with these patients. We searched for articles related to the intrapartum management of pregnant patients with major mental disorders, using 3 main search components: pregnancy, chronic mental illness, and ethics. No articles were found that addressed the clinical ethical challenges of decision making during the intrapartum period with these patients. We therefore developed an ethical framework with 4 components: the concept of the fetus as a patient; the presumption of decision-making capacity; the concept of assent; and beneficence-based clinical judgment. On the basis of this framework we propose an algorithm to guide professionally responsible decision making that asks 5 questions: (1) Does the patient have the capacity to consent to treatment?; (2) Is there time to attempt restoration of capacity?; (3) Is there an opportunity for substituted judgment?; (4) Is the patient accepting treatment?; (5) Is there an opportunity for active assent?; and (6) coerced clinical management as the least worst alternative. The algorithm is designed to support a deliberative, clinically comprehensive, preventive-ethics approach to guide obstetricians in decision making with this challenging population of patients.
Studies have reported that 2% of women have nonaffective psychotic disorders, and approximately half of these women give birth. Given that this prevalence does not account for affective psychosis or agitation and that the age of onset for most of these illnesses is during late adolescence and early adulthood, it is not uncommon for obstetricians to encounter patients with major mental disorders at the time of delivery. Major mental disorders during pregnancy may be compounded by unrecognized medical problems, poor self-care, sexual exploitation, and victimization. These women can also experience unstable living circumstances including homelessness, lack of supportive relationships including absentee fathers, lack of access to both mental health and obstetric care, and lack of integration of psychiatric and obstetric care. 5.6 Furthermore, the use of nicotine, alcohol, and cocaine is more common among women with major mental disorders, including schizophrenia, than in the general population. Denial of pregnancy is a particular problem, not uncommon to this population, and related to a lack of antenatal care and precipitous deliveries. Paranoia and agitation, in turn, can undermine a woman’s ability to comply with obstetric recommendations, especially during the intrapartum period. Although women with major mental disorders often have normal pregnancies and deliveries, the risk of adverse obstetric events and outcomes is increased in this population. In short, pregnant women with major mental disorders present obstetricians with a range of clinical challenges.
These clinical challenges, singly or in combination, can understandably evoke powerful responses, ranging from concern to frustration, foreboding, and even fear. These responses can be magnified when patient presents in labor with a psychosis or agitation and there is limited time for decision making. These responses can bias clinical judgment and the obstetrician’s capacity for professionally responsible decision making.
Given the clinical challenges of this patient population and obstetricians’ responses to them and given the limited time for decision making, obstetricians and liaison-consultation psychiatrists, when they are available, could benefit from a clinically comprehensive decision-making algorithm to use in the intrapartum period ( Figure ). The purpose of this article is to describe this practical tool and its implications for professionally responsible decision making about the intrapartum management of women with major mental disorders. Our goal in proposing this tool is to optimize responsible clinical management with a preventive ethics ( Table ) approach that anticipates and addresses the diminished decision-making capacity of these patients with the goal of preventing ethical conflicts.
| Assent: patients with diminished capacity for decision making should be involved in decision making commensurate with their cognitive abilities and affective state. |
| Beneficence: an ethical principle that obligates the physician to seek the greater balance of clinical goods over clinical harms in the outcomes of patient care. Beneficence-based clinical judgment should be evidence-based. |
| Preventive ethics: the use of the informed consent process to anticipate and address potential conflict in decisions making with patients. |
| Respect for autonomy: an ethical principle that obligates the physician to empower the patient’s decision-making capacity by providing information about medically reasonable alternatives for the management of the patient’s condition. |
| Ulysses contract: an informal advance directive in which a patient with mental illness who has decision-making capacity authorizes medically indicated treatment should the patient later lose decision-making capacity and refuse such treatment. |
Materials and methods
We searched PubMed, PsycINFO, Scopus, and Cochrane databases for articles related to the management of deliveries of pregnant patients with major mental disorders. The 3 main search components were pregnancy, chronic mental illness, and ethics. We used a combination of key words for this search including “pregnancy,” “intrapartum,” “delivery,” “psychosis,” “schizophrenia,” “bipolar disorder,” “severe or chronic mental illness,” “denial of pregnancy,” “paranoia,” “delusional disorder,” “agitation,” and “ethics.” We based our ethical framework on current literature concerning the ethics of obstetric and maternal-fetal medicine and on the requirements of argument-based ethics.
We found no articles focusing exclusively on the intrapartum management of patients with major mental disorders or schizophrenia. We found 2 pertinent articles. One article emphasized the importance of adopting a preventive ethics approach by eliciting patients’ views on the conduct of delivery in advance and one reasoned that a pregnant woman’s autonomy can be justifiably overridden when the pregnant woman refuses to cooperate with cesarean delivery. One author suggested that a temporary guardianship could be indicated if it can be obtained in advance.
Results
Ethical framework
Elsewhere, 3 of us (L.B.M., J.H.C., F.A.C.) have provided an ethical framework for professionally responsible decision making about the intrapartum management of women with major mental disorders. Here we elaborate on this framework as a point of departure.
The first component is the ethical concept of the fetus as a patient. This means that that obstetrician has beneficence-based ( Table ) obligations to the fetus, to protect its health-related interests. Because the fetus is ethically not a separate patient, in all cases the obstetrician’s beneficence-based obligations to the fetal patient must be balanced against the obstetrician’s beneficence-based and autonomy-based ( Table ) obligations to the pregnant woman. This clinically grounded approach distinguishes this ethical framework from the rights-based reductionism of others. The obstetrician’s beneficence-based obligations include making recommendations about intrapartum management based on deliberative (evidence-based, rigorous, and accountable) clinical judgment.
The obstetrician should then implement the ethical and legal presumption of decision-making capacity. This means that the pregnant woman should be involved in decision making, unless she has been reliably judged to lack such capacity. Pregnant women with major mental illness may exhibit chronically and variably impaired autonomy, which may be acutely diminished during the intrapartum period. Patients should not be presumed to lack capacity as a consequence of diagnosis alone or of presenting behavioral signs and symptoms. Instead, decision making must be assessed for the intactness of its components, the ability to: pay attention; absorb, retain, and recall information; reason from events to their likely consequences (cognitive understanding); appreciate that these consequences could happen to oneself (appreciation); assess whether one wants those consequences in one’s life (evaluative understanding); and express a reasoned preference. These elements are being implicitly tested each time the obstetrician engages in the informed consent process with a pregnant patient. Assessment should distinguish between disordered cognitive or affective function that disrupts these components from long-standing personal beliefs that occur independently of the patient’s mental disorder. Assessment should also be sensitive to the potentially distorting effects of labor pain, which can be mitigated with appropriate pain management. When the patient exhibits difficulty with ≥1 these components, formal assessment becomes appropriate and the obstetrician should consider seeking a psychiatric consultation to assist in identifying deficits and addressing those that are modifiable.
The obstetrician should respond to reliably established diminished capacity with an attempt to restore it, which is known as assisted decision making. When such attempts fail, surrogate decision making is required. The surrogate should be guided, in priority order, by the substituted judgment standard and then the best interests standard. Substituted judgment requires the surrogate to reliably report the patient’s preferences, values, and beliefs as the basis for making a decision that the patient would likely make were the patient to possess decision-making capacity. When the surrogate cannot meet this standard, the surrogate should base decisions on the health-related interests of the patient. The obstetrician’s beneficence-based recommendations become the basis for identifying that course of action that upholds the best interests standard.
The concept of assent ( Table ) helps to guide decision making when the patient retains enough of the components of decision-making capacity to express his or her values and preferences. These should be taken into account, with the goal of making decisions with and for the patient by the surrogate decision maker. The concept of assent means that patients are not completely nonautonomous, because they still have some, but limited, capacity to participate in decision making to some degree, even when they cannot exercise the components of decision making to the degree required for informed consent.
For some patients fetal monitoring and cesarean delivery will be well supported in beneficence-based clinical judgment. The pregnant woman has beneficence-based obligations to the fetal patient and future child to take reasonable risks to herself, in order to reduce avoidable risks of vaginal delivery. In clinical circumstances in which the pregnant woman also benefits, this obligation overrides the refusal of cesarean delivery by women whose autonomy is not compromised by major mental illness or any other factor. It therefore follows that the “preferences” of a woman with major mental illness whose decision-making capacity is significantly impaired can also justifiably be overridden. The American College of Obstetricians and Gynecologists takes a similar position: “a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions.”
In implementing this ethically controversial aspect of intrapartum decision making, the obstetrician’s possible responses to this patient population, which we identified above, become relevant. Such feelings can understandably generate a self-protective response that can distort decision making and risks ignoring the pregnant woman altogether. Likewise, these feelings can reinforce concerns to prevent liability by moving quickly, rather than deliberatively, to aggressive obstetric management.
Algorithm
The first step of the algorithm ( Figure ) implements the presumption of decision-making capacity for this population of patients, whom we know to be at risk of diminished decision-making capacity from the chronically and variably impaired autonomy that is a distinguishing feature of major mental illness. Concern about the presumption of capacity may also justifiably be triggered by the woman’s denial of pregnancy or refusal of recommended intrapartum management. Such clinically legitimate concerns do not defeat the presumption. The patient’s decision-making capacity should be carefully assessed.
If the patient’s decision-making capacity is intact, then treatment as usual should be decided in the informed consent process. The algorithm should be held in reserve to guide decision making in response to acute changes in decision-making capacity, such as sudden-onset paranoia or anxiety.
The second step of the algorithm ( Figure ) guides decision making about patients reliably judged to have significantly impaired decision-making capacity. Assisted decision making should be attempted. One component is verbal interventions, such as reminding the woman about how her mental illness can impair her judgment. Verbal interventions can also include reminding her about long-standing values and preferences, including a good outcome to her pregnancy for herself, the fetal patient, and newborn, all of which may be reasonably presumed to be of value by virtue of having carried her pregnancy through to term. The obstetrician should appeal to these values, explain how proposed clinical management supports them, and ask the pregnant woman to accept the proposed clinical management. This is called respectful persuasion. Another component of assisted decision making is rapidly acting pharmacologic interventions that are relatively safe for the pregnant, fetal, and neonatal patients. Medications, including benzodiazepines and antipsychotics, can be administered by mouth or by injection. It should be appreciated that these agents may, in the short term, not eliminate paranoia or anxiety or reverse denial of pregnancy. However, administering such medications may calm patients sufficiently to enable a more meaningful exercise of their decision-making capacity.
The third step of the algorithm ( Figure ) guides decision making when attempts at assisted decision making fail. Decisions at this point will need to be made for the patient, guided in priority order by the substituted judgment standard, to actively incorporate the patient’s preferences, and then by the best interests standard. Some patients may have consented to intrapartum management for maternal or fetal benefit in advance, which can be documented with what is known as a Ulysses contract ( Table ). Such advance consent meets the substituted judgment standard. Oftentimes, the patient may not have available a legally designated surrogate. It is part of the obstetrician’s professional responsibility in such circumstances to act as the patient’s surrogate, with input from all team members aiming to make a deliberative surrogate decision, based on the substituted judgment or best interests standard as appropriate. Organizational policy governing decision making should explicitly identify and support this role.
The fourth step of the algorithm ( Figure ) guides decision making in response to how the patient responds to the plan of care. If treatment is accepted, it should be implemented. We emphasize that the basis for this is not informed consent but rather the assent of the pregnant woman.
The fifth step of the algorithm ( Figure ) guides decision making when the patient who has significantly impaired decision-making capacity refuses treatment and attempts at respectful persuasion fail. The response should be one last attempt to obtain assent by recycling verbal and pharmacologic efforts to support assisted decision making and respectful persuasion. For example, the salutary effects on decision-making capacity of a short-acting medication may diminish or disappear during the course of prolonged labor. A change in caregiver may facilitate this last attempt to obtain assent. Documenting how the 5 questions in the algorithm were addressed should be incorporated into the obstetrician’s postdelivery record entry.
The sixth step of the algorithm ( Figure ) closes with consideration of cases in which all attempts at assisted decision making fail. Beneficence-based obligations to the fetal patient become the guiding consideration. Postponing cesarean delivery may also increase the potential for maternal complications, especially from poorly controlled paranoia and anxiety. In such clinical circumstances, proceeding to cesarean delivery becomes ethically justified. This may be ethically the least worst alternative, when compared to nonintervention. The obstetrician should explain what is going to happen to minimize confusion, fear, and psychological trauma and proceed to coerced clinical management. The care team should be alert to signs and symptoms of posttraumatic stress disorder in the months following delivery.
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