CLINICAL CASE
Unit One: Approach to the Patient
Objective 6: Legal and Ethical Issues in Obstetrics and Gynecology
Case 1
Mrs. Smith, whose delivery was imminent, was admitted through the emergency
room. All beds in L&D and on the Ob floor were full, so she was sent to a nonobstetrical floor.
The attending physician evaluated the patient and ordered a prostaglandin
suppository. The nurse called the resident, advising him that he needs to give this
patient a suppository. Upon his arrival, the nurse gave the resident the unwrapped
suppository. The resident was somewhat surprised at the use of the suppository
because the usual protocol at this hospital for ripening the cervix was a prostaglandin
gel rather than the suppository. The nurse noted the attending’s order stating a
suppository. The resident did know that other hospitals often used 3mg compound
prostaglandin suppositories for cervical ripening. The resident did not realize that the
only dosage of pre-packaged prostaglandin suppositories for this hospital was 20 mg,
which are only indicated for the induction of abortion.
The resident administered the suppository, but was later called back to Mrs. Smith’s
room because she was having some very strong contractions – too strong when
compared to patients in similar situations. He used a Doppler, but was unable to
detect fetal heart tones. After checking the patient’s chest and heart, he administered
Terbutaline to relax the uterus and assist with fetal blood flow. He followed up with
an ultrasound and thought, but wasn’t certain, that he detected a fetal heartbeat.
Another OR resident arrived to assist the first resident. The second resident
conducted her own ultrasound and, on seeing nothing, advised the patient that her
baby was dead.
The first resident, having little confidence, never told the second resident or attending
that he thought he saw a heartbeat. No other scans were performed.
The patient was counseled in preparation for delivery of the deceased fetus. The fetal
condition was not monitored and numerous pharmaceuticals were administered in
accordance when there is a dead fetus.
Upon delivery, it was realized that the fetus was alive. The baby boy was
immediately taken to NICU. The baby survived with no lasting problems.
Management discussion
1. Why might being sent to a non-obstetrical floor make a difference in this case
as compared to being sent to an obstetrics floor?
2. Did the attending physician write the order correctly? What could the
attending have done throughout this case?
3. Do you think the nurse handled the situation in the correct manner?
4. What error(s) did the junior resident make? Why do you think he might have
made the error(s)?
5. Did the second resident help or hinder the process? Explain your answer.
6. Did the hospital pharmacy have a role in this confusion?
7. What correct action did the first resident make regarding administering of
drugs?
8. If you were judge and jury, where would you lay the fault?
Teaching points
1. When ordering medication, always specify the dosage and do so legibly. It is
suggested that you put your beeper number on the order in case there are
questions.
2. Never administer a medication handed to you if you are not clear about the
dosage and/or the reason for administering it.
3. Never be afraid to question something someone tells you to do – it might not
always be in the patient’s best interest.
4. Administering unpackaged medication is dangerous – check the packaging
and do not be afraid to question perceived authority.
5. Be very familiar with the formulary at any facility where you will be ordering
medications.
6. Admit patients to areas of the hospital where nursing staff is familiar with
their condition, needs and typical treatments.
7. Never be too timid or intimidated to give your clinical findings. In this case,
the junior resident should have noted the possible presence of a heartbeat. It
probably would have forced the senior resident to look more closely and
perhaps caused the attending to look at it himself.
8. In times of crisis, always make certain (as best you can) that you are not
doing more harm than good.
9. Do not tell a patient her baby is dead unless you are very, very certain.
Case 2
The 17-year-old daughter of one of your patients comes to see you in your office. You
saw her in your office once before, when she was 16 years-of-age. At that time, she
appeared healthy and this was supported by the pelvic examination. She explains to
you that her mother brought her for this appointment and thinks she is just here for
an annual pelvic examination. However, as it turns out, the patient asks to be placed
on birth control pills. She has been sexually active with her boyfriend for six months.
Discussion reveals that she intends to continue sexual activity, including engaging in
intercourse. Up to this point, they have used the withdrawal method. She does
experience somewhat painful menstrual periods and they are not always regular.
After conducting the pelvic examination and further discussion, you decide to place
her on an oral contraceptive to prevent pregnancy. In addition to explaining the use
of oral contraceptives, you provide information about sexually transmissible diseases.
Upon leaving the examine room, her mother stops you and asks how her daughter is
doing and to tell her about the nature of her visit.
1.
2.
3.
4.
Consider what you would say to the patient’s mother at this time.
Consider why you would or would not tell her this.
Consider if you would express it to her in this manner and if not, how
you would change it.
Consider in what order you would use these ideas/items (if at all).
Tell Mother
Comment to Mother
Yes or No
I cannot tell you anything about your daughter's
Why/Why Not visit because it would be a breach of confidentiality
How Change
Order
Yes or No
You need to ask your daughter about this visit,
Why/Why Not rather than me.
How Change
Yes or No
As you may know, your daughter is sexually active
Why/Why Not and I have found it best to make every effort to
prevent pregnancy, so I prescribed oral
How Change
contraceptives.
Yes or No
Why /Why
Not
How Change
Your daughter came to me worried about her period.
Yes or No
Your daughter is experiencing dysmenorrhea.
Why/Why Not
How Change
Tell Mother
Comment to Mother
Yes or No
Your daughter is experiencing dysmenorrhea and I
Why/Why Not believe it is in her best interest that we prescribe oral
Order
How Change
contraceptives.
Yes or No
She asked to be put on an oral contraceptive and
Why/Why Not after some discussion; I have to agree with her.
How Change
Yes or No
Why/Why not
How Change
Do you know of the discomfort your daughter is
having with her period?
Yes or No
Why do you think your daughter came to see me?
Why/Why Not
How Change
Yes or No
Don’t worry; it wasn’t about anything that is really
Why/Why Not serious.
How Change
Teaching points
1.
2.
3.
The nature of the dilemma herein is information exchange.
A few questions to ask include:

What does the patient expect from you?

What do you expect from yourself as a physician?

Do your expectations of yourself match likely patient
expectations of you?

Are there serious differences between what you and your patient
agree upon and expectations of society at large?

What are the moral obligations to provide information to
persons other than the patient?

What is the role of confidentiality in this case?
Some guidelines about this information exchange are:

There is a general moral obligation not to give misinformation
or tell a direct lie.

There is no general moral obligation to tell “the whole truth,”
i.e. give others, including the mother, all the information we
possess.

There is a moral obligation to provide beneficial information in
the physician-patient relationship (if you tell the mother about
her daughter’s sexual activity, should you tell the daughter you
have shared that information?).
4.
The legal issue is consent to medical treatment. In other words, what is
needed in your state to be considered sufficient consent? Can a minor
consent? Whatever the law in your state, are there exceptions?