Eduovisual
Ethics, Communication & Professionalism
Gestational decision-making and maternal-fetal conflict
— Refusal of cesarean delivery for non-reassuring fetal status, placenta previa with hemorrhage, or breech presentation
— Refusal of blood products (e.g., Jehovah's Witness) with peripartum hemorrhage
— Continued substance use (opioids, alcohol, tobacco) in pregnancy
— Refusal of antiretrovirals in HIV-positive pregnancy
— Declining recommended diabetes, hypertension, or seizure therapy
— Home birth after high-risk obstetric history
— Late-term decisions about resuscitation of a periviable neonate (22–25 weeks)
— ACOG explicitly opposes coercive interventions, court-ordered cesareans, and criminalization of maternal behavior in pregnancy.
— AMA and AAP align: respect informed refusal; pursue persuasion, not force.
— Words like "refuses," "against medical advice," "court order," "Child Protective Services," or "patient is competent"
— A capacitated pregnant adult making a choice the team disagrees with
Board pearl: On Step 3, forcing a procedure on a competent pregnant patient is essentially never the right answer, even when fetal harm is likely. The correct response is shared decision-making, ethics consult, and documentation — not court intervention.
— A 28-year-old G2P1 at 39 weeks with category III tracing refuses cesarean; she is alert, oriented, and understands risks
— A 32-year-old Jehovah's Witness at 34 weeks with placenta accreta refuses transfusion even if life-threatening
— A 24-year-old at 30 weeks tests positive for cocaine; nurse asks whether to report to CPS
— A 36-year-old HIV-positive woman refuses antiretrovirals; viral load is high
— A 22-year-old at 23 weeks 5 days in preterm labor declines neonatal resuscitation
— Decision-making capacity assessment: Can the patient (1) communicate a choice, (2) understand information, (3) appreciate how it applies to her, (4) reason through options? All four must be intact.
— Reasoning behind refusal: religious, cultural, prior trauma (e.g., obstetric violence), fear, mistrust, misinformation
— Social context: partner coercion, intimate partner violence, housing, immigration concerns that affect disclosure
— Prior obstetric history: prior cesarean, prior loss, prior NICU experience often drives current preferences
— Substance use history: what, how much, route, last use — obtained nonjudgmentally; screening is universal, not selective by race or socioeconomic status
— Elicit her understanding first, share medical recommendation, then re-elicit
— Use teach-back to confirm comprehension of risks
— Offer harm-reduction alternatives (e.g., cell saver instead of allogeneic blood; methadone instead of abstinence)
Key distinction: Capacity is a clinical determination made by the treating physician for a specific decision at a specific time; competence is a legal determination by a court. Step 3 stems often hinge on you recognizing that a patient who disagrees with you is not therefore incapacitated. Disagreement ≠ incapacity.
— Vitals: hypotension, tachycardia suggesting hemorrhage or sepsis that may impair cognition
— Mental status: alert, oriented ×3, attention intact, no fluctuation suggesting delirium
— Signs of intoxication: pupils, nystagmus, slurred speech, odor — acute intoxication impairs capacity
— Signs of intimate partner violence: bruising in varied stages, controlling partner present, patient deferring to partner
— Fetal heart tones, category I/II/III tracing
— Estimated fetal weight, presentation, gestational age
— Biophysical profile when relevant
— Understanding: Can she paraphrase the diagnosis and proposed treatment?
— Appreciation: Does she apply the information to her own situation? ("My baby could die" vs. "babies in general die")
— Reasoning: Can she weigh risks and benefits coherently?
— Choice: Can she communicate a stable decision?
— Higher-stakes refusals (declining life-saving cesarean) demand a higher threshold of demonstrated capacity
— A patient may have capacity for one decision and not another
Step 3 management: If a pregnant patient refuses an urgent intervention, document the capacity assessment in the chart with specific quotes demonstrating understanding, appreciation, reasoning, and choice. This single act both protects the patient's autonomy and protects the clinician medico-legally. A note that says only "patient refuses, AMA" without a capacity assessment is a Step 3 wrong answer and a real-world liability.
— Confirm gestational age (LMP, first-trimester ultrasound)
— Confirm fetal status (NST, BPP, ultrasound)
— Confirm maternal status (CBC, type and screen, coags if bleeding; toxicology if indicated; HIV viral load if relevant)
— Is this emergent (minutes, e.g., uterine rupture), urgent (hours, e.g., severe preeclampsia), or elective (days–weeks, e.g., mode of delivery planning)?
— Time available dictates how much deliberation, ethics consultation, and family meeting is feasible
— Religious advance directives (e.g., Jehovah's Witness blood card)
— Birth plan documents
— Health care proxy / surrogate identification — important if she later loses capacity
— Maternal autonomy vs. fetal beneficence
— Maternal autonomy vs. clinician beneficence toward mother
— Maternal vs. partner/family preferences (the partner does not have decision-making authority over a capacitated pregnant adult)
— Universal verbal screening (4 P's, NIDA Quick Screen) at first prenatal visit
— Urine toxicology only with patient consent in most states; know your state law
— Avoid selective drug testing by demographics — this is discriminatory and a Step 3 trap
— Private interview without partner present
— Validated screening (HITS, HARK)
Board pearl: Toxicology testing of a pregnant patient or newborn without maternal consent or clear clinical indication is both an ethical violation and, in several states, legally actionable. Universal verbal screening is the standard; biologic testing requires informed consent except in defined emergencies.
— Persistent disagreement after good-faith communication
— Capacity is genuinely unclear (e.g., severe depression, intoxication resolving, intellectual disability)
— Team members are morally distressed or disagree among themselves
— Decision is irreversible and high-stakes (refusal of life-saving cesarean, withdrawal of neonatal resuscitation at periviable gestation)
— Considering involvement of risk management, legal, or (rarely) the court
— Multidisciplinary: ethics, OB, neonatology, anesthesia, nursing, social work, chaplaincy
— Patient and chosen support persons included whenever possible
— Written recommendation in the chart; non-binding but highly weighted
— Indicated when there is concern for psychiatric illness affecting reasoning (psychosis, severe depression with nihilistic delusions, mania)
— Psychiatric diagnosis alone does not equal incapacity — many patients with depression or schizophrenia retain decisional capacity
— Detailed anatomy ultrasound, fetal echo, MRI for anomalies that change prognosis and may reframe the discussion (e.g., lethal anomalies)
— Genetic counseling for results that affect decisions about delivery or resuscitation
— Joint OB–neonatology counseling
— Discuss intentional vs. comfort-focused resuscitation
— Document parental preferences; revisit at threshold changes
Key distinction: Ethics consultation is advisory; court intervention is coercive. ACOG and the AMA strongly discourage seeking court orders to override a capacitated pregnant patient's refusal. Even when courts have ordered cesareans historically, appellate review has overwhelmingly rejected those orders (e.g., In re A.C., 1990). On Step 3, "obtain court order to compel cesarean" is essentially always wrong.
— Step 1: Assess capacity for this specific decision. If lacking → identify surrogate (health care proxy, spouse, adult child per state hierarchy) and proceed with surrogate decision-making in patient's best interest.
— Step 2: If capacity intact → explore reasons for refusal (fear, religion, prior trauma, misinformation, mistrust).
— Step 3: Provide clear information about risks/benefits/alternatives using teach-back.
— Step 4: Offer acceptable alternatives or harm-reduction (cell saver, erythropoietin, regional vs. general anesthesia, expectant management with close monitoring).
— Step 5: Engage multidisciplinary support — chaplain, social work, cultural liaison, ethics.
— Step 6: If refusal persists, respect the decision, document thoroughly, plan for the next contingency (e.g., what to do if hemorrhage occurs), maintain therapeutic relationship.
— Coerce, threaten loss of custody, threaten to "call the judge"
— Obtain a court order to perform cesarean on a capacitated patient
— Discharge the patient or "fire" her from the practice for refusal
— Allow personal moral views to override patient-centered care
— Quantify risks ("approximately 50% risk of fetal death" vs. vague "very dangerous")
— Numbers improve informed refusal and improve documentation
Step 3 management: If a Jehovah's Witness with postpartum hemorrhage refuses blood, first-line management is aggressive non-blood resuscitation: uterotonics (oxytocin, methylergonovine, carboprost, misoprostol), tranexamic acid, balloon tamponade, uterine artery embolization, cell salvage, IV iron and erythropoietin, hysterectomy if needed. Respect the directive even if she becomes unconscious — a properly executed advance directive remains valid.
— SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary
— NURSE statements: Name, Understand, Respect, Support, Explore emotions
— Ask-Tell-Ask: Elicit understanding → share information in small chunks → check comprehension
— "I wish" statements: "I wish we had safer options" acknowledges emotion without abandoning recommendation
— Opioid use disorder in pregnancy: First-line is medication-assisted treatment with methadone or buprenorphine, not abstinence or detoxification (detox increases relapse and fetal risk). Refusing to offer MAT is substandard care.
— HIV in pregnancy: Antiretroviral therapy reduces vertical transmission from ~25% to <1%. Counsel strongly, but cannot force. Respect refusal; document; offer at every visit; plan neonatal prophylaxis (zidovudine ± nevirapine) — though neonatal treatment also requires parental consent post-delivery (with state child welfare pathways if refused).
— Tobacco/alcohol: Brief intervention, NRT considered (patches/gum) when behavioral fails; naltrexone/acamprosate generally avoided in pregnancy; refer to MAT-equivalent counseling.
— Mental health: SSRIs (sertraline preferred) when benefits outweigh risks; untreated maternal depression itself harms the fetus.
— Address fear (often of pain, loss of control, prior trauma) rather than reflexively medicating
— Doula support, epidural early, trauma-informed care often more effective than anxiolytics
Board pearl: Methadone or buprenorphine maintenance is the standard of care for opioid use disorder in pregnancy — Step 3 will test this. Mandatory abstinence, naltrexone induction, and threats of CPS reporting as a "motivator" are wrong answers. Treat addiction as a chronic disease; engage, don't punish.
— Review all clinical data; align team on facts and recommendation before meeting
— Identify decision, decision-maker, and timeline
— Secure private setting, adequate time, interpreter (in-person or video — never family member for medical decisions)
— Invite chosen support persons; confirm patient consents to their presence
— Introductions, roles, purpose
— Elicit patient understanding first ("Tell me what you've been told")
— Share medical information in plain language; avoid jargon
— Acknowledge emotion explicitly; tolerate silence
— Explore values: "What matters most to you about this pregnancy and birth?"
— Make a recommendation, do not just lay out options ("Given what matters to you, I recommend…")
— Negotiate alternatives and contingencies
— Summarize, confirm understanding with teach-back, document
— Offer second opinion
— Offer transfer of care if patient desires
— Ethics consultation
— Continue to provide all other indicated care — refusal of one intervention does not mean refusal of all
— A clinician may decline to perform a procedure they find morally objectionable (e.g., termination)
— Must disclose objection, must not abandon, must arrange timely transfer to a willing provider, must provide emergency care regardless
CCS pearl: In a CCS-style case, when a pregnant patient refuses a recommended intervention, your high-yield orders are: "Assess decision-making capacity," "Family meeting," "Ethics consultation," "Social work consultation," "Chaplain services," and "Document refusal and counseling." Do not order "court order" or "involuntary procedure" — these will tank your score.
— In most US states, pregnancy itself emancipates the minor for decisions regarding her pregnancy and the resulting child — she can consent to and refuse prenatal care, delivery mode, and routine pediatric care for her infant
— Parental notification/consent for abortion varies by state (some require parental involvement, often with judicial bypass)
— Confidentiality regarding STI testing, contraception, prenatal care is generally protected
— Always assess for statutory rape, trafficking, IPV — mandatory reporting may apply for sexual abuse of a minor
— Capacity is decision-specific; many patients with intellectual disability or early dementia retain capacity for some pregnancy decisions
— Use supported decision-making: simplified information, repetition, trusted support person
— If capacity is lacking → surrogate decision-maker per state hierarchy; decisions made in patient's best interest with consideration of her known values
— Sterilization of cognitively impaired women requires extraordinary safeguards (often court approval) — a long shadow of eugenic abuses
— Schizophrenia, bipolar disorder, severe depression — diagnosis ≠ incapacity
— Assess capacity at the time of the specific decision
— Treat the psychiatric illness; untreated illness is the bigger threat to capacity and to mother/fetus
— Involuntary psychiatric hold is for danger to self/others, not for protecting the fetus per se
— Right to medical care, including reproductive care, including abortion (where legal)
— Shackling during labor is prohibited by federal law (First Step Act, 2018) and most state laws
Key distinction: A pregnant minor can generally consent to prenatal care for herself, but parental involvement laws may apply to abortion. Two different legal regimes — Step 3 may probe this distinction.
— Refuse whole blood, RBCs, platelets, plasma, WBCs
— Accept (individually variable): albumin, clotting factors, immunoglobulins, erythropoietin, cell salvage, hemodilution, organ transplant
— Carry advance directive cards — honor even when unconscious
— Prenatal planning is essential: IV iron, erythropoietin to optimize hemoglobin; identify hemorrhage risk early (placenta accreta spectrum)
— May decline most medical interventions; respect adult decisions
— Children, including the newborn, are a separate matter — denial of life-saving care to a child is grounds for CPS involvement regardless of parental religion
— Modesty preferences (female provider requests), family-centered decision-making norms, traditional birth practices
— Use professional interpreters, not family
— Do not assume; ask about preferences explicitly
— Joint OB–neonatology counseling on survival and disability outcomes (use current data: ~22 weeks ~30% survival with active care, ~25 weeks ~80%)
— Parental values drive decision: active resuscitation vs. comfort care
— Document plan; reassess if gestational age advances or condition changes
— Either choice is ethically permissible at the lower threshold
— Newborn is a separate patient with independent rights
— Parental refusal of clearly life-saving newborn care (e.g., antibiotics for sepsis, surgery for gastroschisis) → engage ethics, CPS, and (rarely) court order
— This is fundamentally different from intrauterine refusal
Board pearl: The legal and ethical calculus changes the moment of birth. Before birth: maternal autonomy is paramount. After birth: the neonate is an independent patient, and parental refusal of life-saving care can trigger state intervention.
— Fetal/neonatal death, hypoxic-ischemic encephalopathy, cerebral palsy
— Maternal hemorrhage, hysterectomy, death
— Vertical transmission of HIV, hepatitis, syphilis
— Neonatal abstinence syndrome
— Preterm birth, IUGR from uncontrolled chronic disease
— Court-ordered cesareans have caused maternal injury, loss of trust, and have been overturned on appeal (In re A.C., Pemberton v. Tallahassee Memorial)
— Coerced or covert testing erodes prenatal engagement → women avoid prenatal care altogether
— Punitive substance use reporting reduces disclosure and worsens outcomes
— Birth trauma, PTSD from coercive care
— Loss of trust in medical system; avoidance of future care
— Strained therapeutic alliance
— Family conflict, partner violence escalation
— Disparities: Black, Indigenous, and low-income women are disproportionately subject to coercive interventions and CPS reporting despite similar rates of substance use across groups
— Loss of public trust in obstetrics
— Common when honoring a refusal that leads to bad outcome
— Mitigate with team debriefing, ethics support, schwartz rounds
— Moral distress is not a reason to override autonomy
— Lawsuits more commonly arise from failure to obtain informed consent or performing unauthorized procedures than from honoring documented refusals
— Thorough documentation of capacity assessment, risks discussed, alternatives offered, and patient's stated reasons is the best protection
Step 3 management: After an adverse outcome following a respected refusal, the correct steps are: provide ongoing supportive care, debrief the team, offer the patient/family bereavement support, complete a non-punitive root cause/event review, and document the trajectory of decision-making — not retrospectively second-guess the patient's autonomous choice.
— Capacity is unclear after initial assessment
— Persistent team-patient or intra-team disagreement
— Irreversible high-stakes decisions
— Surrogate decision-maker's choices appear inconsistent with patient's known values
— Newborn life-sustaining treatment decisions are contested
— Considering against-medical-advice discharge with high acuity
— Patient lacks identifiable surrogate and decision must be made
— Court guardianship may be needed (rare, almost never for the pregnancy decision itself)
— Mandatory reporting law applies to the situation in your state
— Suspected child abuse or neglect of an existing child
— Newborn with positive toxicology in states requiring report (varies — know the difference between "report" and "prosecute")
— Parental refusal of clearly life-saving treatment for a born child
— Punish prenatal substance use (counterproductive; reduces prenatal care utilization)
— Compel intrauterine procedure on capacitated woman
— Coerce treatment adherence
— Refusing patients still deserve full medical care — admit if clinically indicated regardless of refusal of one intervention
— Psychiatric admission only for danger criteria, not "for the baby"
— Level I–IV designation (ACOG/SMFM); high-risk refusers may benefit from Level III/IV transfer for resources and expertise
— Honor refusals while optimizing setting and contingency planning
CCS pearl: In CCS, "ethics consultation," "social work consultation," "psychiatry consultation for capacity evaluation," and "case management" are high-yield orders in maternal-fetal conflict scenarios. They demonstrate appropriate escalation without coercion. Avoid "consult legal to obtain court order" — that is almost always the distractor.
— Informed refusal: capacitated patient declines after understanding → respect
— Lack of capacity: surrogate decides → may consent on patient's behalf
— Test: capacity assessment with the four abilities
— Before birth: maternal autonomy governs
— After birth: standard pediatric ethics — best interest of the child, parental authority bounded by harm principle
— When patient lacks capacity and surrogates disagree (e.g., husband wants resuscitation, mother wants comfort), follow state surrogate hierarchy; ethics consult; advance directive prevails if available
— Objection: clinician declines specific service, arranges transfer, provides emergency care
— Abandonment: clinician unilaterally ends care without arrangement → unprofessional and actionable
— Historically allowed withholding information thought harmful to patient
— Largely rejected in modern practice; full disclosure is the standard with rare narrow exceptions
— In pregnancy, partner notification (e.g., HIV, IPV) follows usual rules — patient confidentiality with narrow exceptions
— Historically pregnant women excluded; current ethics favors inclusion with appropriate safeguards to generate evidence (e.g., COVID vaccine data)
Key distinction: Conscientious objection is permissible; conscientious abandonment is not. A clinician who declines to perform a tubal ligation must still document the request, ensure timely referral to a willing provider, and continue all other care. On Step 3, "decline and refer" is right; "decline and discharge from practice" is wrong.
— Acute medical illness (sepsis, hypoxia, hypoglycemia, magnesium toxicity in preeclampsia) → fluctuating attention, disorganized thought
— Treat underlying cause; capacity may return
— Surrogate decides in the interim if intervention is time-sensitive
— Acute intoxication impairs capacity
— Allow time to clear if clinically feasible; surrogate or emergency exception if not
— Pain and active labor do not automatically negate capacity, but can compromise it
— Decisions about delivery mode should ideally be made antepartum
— A previously documented birth plan carries weight
— Hypovolemic shock impairs capacity → fall back on prior advance directives (e.g., Jehovah's Witness card)
— Surrogate decision-maker for non-directive decisions
— "Refusal" may actually be misunderstanding
— Use professional interpreter, teach-back, written materials at appropriate literacy level
— Reassess "refusal" after true comprehension established
— Apparent refusal may reflect IPV or family pressure
— Private interview without partner; screen for IPV
— A coerced decision is not an autonomous decision
— Severe depression with suicidality, psychosis with delusions about pregnancy/fetus → may affect capacity
— Psychiatry consultation; treat illness; reassess capacity
Board pearl: Before accepting a "refusal" at face value, rule out reversible confounders: delirium, intoxication, pain, language barrier, coercion, untreated psychiatric illness. Many "refusals" dissolve when the underlying issue is addressed. This is both ethically and clinically essential.
— Refusal of one intervention is not refusal of the clinician or the relationship
— Continue prenatal visits, monitoring, and offering recommended care
— Avoid punitive tone; reaffirm commitment to her care
— Capacity assessment, content of discussions, alternatives offered, patient's stated reasoning, plan for contingencies
— Share with covering providers, L&D team, anesthesia
— Pre-emptive multidisciplinary huddle before delivery if known refusal (e.g., JW with placenta previa)
— Encourage health care proxy designation
— Document preferences regarding blood products, intubation, ICU care, neonatal resuscitation at periviability
— Revisit each trimester and at clinical inflection points
— Continue MAT through pregnancy, delivery, and postpartum
— Postpartum is the highest-risk period for relapse and overdose — do not taper MAT after delivery
— Coordinate with addiction medicine, pediatrics, social work
— Naloxone prescription at discharge
— Continue ART; viral load monitoring; intrapartum AZT if viral load >1000
— Neonatal post-exposure prophylaxis
— Avoid breastfeeding in US (where formula is safe and available)
— Postpartum depression screening (EPDS) at 2, 6 weeks and beyond
— Continue or initiate SSRIs as indicated; sertraline preferred in lactation
— Address before discharge; respect autonomy regarding LARC, sterilization, none
— Postpartum LARC increasingly offered immediately
Step 3 management: For opioid use disorder, continue MAT postpartum and prescribe naloxone. Postpartum dose requirements may decrease; coordinate dose adjustment with addiction medicine. Abrupt MAT discontinuation postpartum is a leading driver of maternal overdose death.
— Contact within first 3 weeks postpartum (in-person, telehealth, or home visit)
— Comprehensive visit by 12 weeks postpartum
— Higher-frequency follow-up for high-risk conditions: hypertensive disorders (1–2 weeks), diabetes (6–12 weeks with 2-hour GTT for GDM), mental health, substance use
— Post-PPH JW patient: hemoglobin, iron studies, continue IV iron/EPO until recovery
— Post-NAS infant: pediatric follow-up, developmental surveillance, early intervention referrals
— HIV-exposed infant: serial HIV PCR, prophylaxis course, pediatric ID follow-up
— Hypertensive disorders: BP monitoring; lifetime CV risk counseling
— Process the birth experience — especially after contested decisions or adverse outcomes
— Screen for postpartum depression, anxiety, PTSD (birth trauma)
— Contraception and interpregnancy interval planning (≥18 months recommended)
— Long-term health implications (preeclampsia → lifetime CV risk; GDM → T2DM screening every 1–3 years)
— Substance use relapse prevention
— OB to primary care handoff with explicit summary
— Mother-infant dyad care coordination
— Mental health warm handoff if indicated
— Review what happened, what risks recur, what can be modified
— VBAC counseling if prior cesarean
— Preconception optimization
Board pearl: The "fourth trimester" concept — comprehensive postpartum care extending through 12 weeks — is now standard per ACOG. A single 6-week visit is no longer adequate. Step 3 increasingly tests early contact (within 3 weeks), comprehensive visit by 12 weeks, and risk-stratified higher-frequency follow-up.
— Autonomy of the pregnant patient is the dominant principle in US bioethics and law
— Beneficence toward the fetus is exercised through the mother, not against her
— Nonmaleficence prohibits coercion, deception, and abandonment
— Justice requires non-discriminatory care across race, class, and substance use status
— In re A.C. (1990, DC): court-ordered cesarean overturned; pregnant patients have right to refuse
— Pemberton v. Tallahassee Memorial (1999): cautionary opposite outcome — court-ordered cesarean; widely criticized
— ACOG Committee Opinion #664 (reaffirmed): opposes coercive interventions
— A laboring patient receives epidural; can she still consent to cesarean? Yes — pain/analgesia do not automatically negate capacity if she meets the four abilities
— Emergency exception: when delay would cause serious harm and patient cannot consent, treat under implied consent — but does not apply if a capacitated patient has explicitly refused
— Spousal/partner consent is not required for any obstetric procedure on a capacitated adult
— Child abuse/neglect of existing children: mandatory in all states
— Prenatal substance exposure: state-variable; some require report at birth, some criminalize, some treat as public health — know your state
— Suspected trafficking, abuse of vulnerable adults: mandatory in most states
— IPV in pregnant adults: generally not mandatory to report without patient consent (varies)
— Handoff from OB to ED, ICU, anesthesia must explicitly transmit known refusals (e.g., JW status), advance directives, and capacity determinations — a missed handoff is a sentinel-event risk
— Adverse outcomes after respected refusals deserve non-punitive review, focused on system support not blame on patient choice
Step 3 management: When a pregnant patient with a documented Jehovah's Witness advance directive arrives unconscious with hemorrhage, honor the directive. Transfusing against a valid advance directive — even to save life — is battery and a sentinel event. Use all non-blood options aggressively; document everything.
Board pearl: When in doubt on a maternal-fetal conflict question, the answer almost always involves respecting autonomy, exploring reasoning, offering alternatives, ethics consultation, and meticulous documentation — never court orders, never coercion, never CPS as a threat tool during pregnancy.
"39-week G2P1, category III tracing, refuses cesarean; alert, oriented, understands risks. Next step?"
→ Continue counseling, ethics consult, respect refusal if capacity intact. Not court order.
"Hemorrhaging post-vaginal delivery; carries blood refusal card; becoming hypotensive. Next step?"
→ Uterotonics, TXA, balloon, cell salvage, IV iron/EPO, hysterectomy if needed. Do not transfuse.
"Urine tox positive at 30 weeks. Nurse asks if you should report to CPS. Best response?"
→ Counsel, offer treatment, supportive care; reporting requirements vary by state — punitive reporting reduces engagement.
"16-year-old G1P0 at 20 weeks presents alone; wants prenatal care without informing parents. Action?"
→ Provide care; pregnancy emancipates for prenatal decisions in most states.
"Viral load 50,000; declines ART. Next?"
→ Continue counseling at each visit; respect refusal; plan intrapartum AZT discussion, neonatal prophylaxis (with parental consent post-delivery).
"23 0/7 weeks, parents asking about resuscitation. Best approach?"
→ Joint OB-neonatology counseling; survival/disability data; honor parental values; either active or comfort care acceptable.
→ Wife's autonomous decision governs; husband has no veto.
"Patient with schizophrenia refuses recommended induction. Action?"
→ Assess capacity using four abilities; diagnosis alone does not equal incapacity.
"Resident asked to assist with termination, declines on moral grounds. Correct action?"
→ Disclose, arrange coverage by willing provider, continue all other care; do not abandon.
"Patient with OUD on buprenorphine, postpartum day 2. Best plan?"
→ Continue buprenorphine, prescribe naloxone, coordinate addiction follow-up, screen for postpartum depression.
Key distinction: The wrong-answer pattern is consistent — coercion, court orders, threats, abandonment, and selective testing. The right-answer pattern is also consistent — capacity assessment, counseling, ethics consult, alternatives, documentation, and sustained engagement.
A capacitated pregnant patient has the same right to refuse recommended care as any other adult, and the clinician's task in maternal-fetal conflict is to assess capacity, explore reasons, offer alternatives, engage ethics, and document — never to coerce, never to seek a court order, never to abandon.
Board pearl: If the question asks what to do when a competent pregnant patient refuses a recommended intervention and one option is "obtain a court order to compel treatment," that option is the distractor — every time. Pick the answer that honors her voice, supports her with the team, and writes it all down.