What to do when a 16-year-old female in severe epigastric pain, with a relative (family member) present, requires an urgent cesarean section (C-section) but denies being pregnant?

Management of Urgent Cesarean Section in a 16-Year-Old Denying Pregnancy

Proceed with urgent cesarean section based on clinical findings and objective evidence of pregnancy, not the patient's denial, as a 16-year-old has the legal capacity to consent but her denial does not negate objective medical reality in a life-threatening emergency. 1

Legal Capacity and Consent in 16-17 Year Olds

• 16- and 17-year-olds are presumed to have capacity to consent to treatment as if they were adults and it is not necessary to obtain consent from parents or guardians when the young person has capacity 1
• However, consent can also be given by those with parental responsibility for the young person, whether or not she lacks capacity 1
• In this scenario, the patient's denial of pregnancy despite objective clinical evidence (severe epigastric pain requiring urgent cesarean section) suggests either:
  • Psychological denial/dissociation from reality
  • Acute stress response impairing judgment
  • Potential loss of capacity due to pain, anxiety, or medical compromise 1

Assessment of Decision-Making Capacity

• Drugs, fatigue, pain, or anxiety may compromise capacity but do not necessarily lead to incapacity unless the degree of compromise is severe 1
• The patient's statement "I am not pregnant" when objective findings indicate pregnancy requiring urgent cesarean section suggests impaired capacity to understand and process medical information in this acute situation 1
• A presumption of capacity remains, but this can be rebutted when the patient demonstrates inability to understand, retain, or weigh relevant information 1

Immediate Management Algorithm

Step 1: Rapid Capacity Assessment (30-60 seconds)

• Assess whether the patient can understand that she is pregnant based on objective findings 1
• Determine if severe pain or psychological distress is impairing her ability to process information 1
• If capacity is clearly compromised by pain, anxiety, or denial, proceed to Step 2 1

Step 2: Obtain Consent from Parent/Guardian

• Since the relative is present and can provide consent for the 16-year-old, obtain consent from the parent/guardian immediately 1
• This is legally valid whether or not the patient has capacity 1
• Do not delay for ethics committee consultation in a true emergency requiring urgent cesarean section 1

Step 3: Proceed with Urgent Cesarean Section

• Maternal safety is the greater priority for the anaesthetist, though women willingly accept some risk to ensure good neonatal outcome 1
• In law, a pregnant woman with capacity can refuse treatment even if it puts the unborn child at risk, but this patient's denial of objective reality suggests impaired capacity 1
• Emergency cesarean section should not be delayed when there is fetal compromise or maternal indication 2, 3

Critical Timing Considerations

• Fetal distress with irreversible causes (major placental abruption, fetal hemorrhage, umbilical cord prolapse) requires immediate cesarean section 2
• HELLP syndrome or acute fatty liver presenting with severe epigastric pain requires urgent delivery to improve maternal and perinatal outcomes 1, 2
• Delaying for ethics committee consultation in a true obstetric emergency increases maternal and fetal morbidity and mortality 1

Common Pitfalls to Avoid

• Do not respect a refusal based on denial of objective medical reality when capacity is compromised 1
• Do not delay urgent cesarean section for ethics committee consultation when parental consent is available and the situation is life-threatening 1
• Do not assume that a 16-year-old's verbal refusal automatically overrides parental consent, especially when capacity is questionable 1
• Severe epigastric pain in pregnancy can indicate HELLP syndrome, hepatic rupture, or uterine rupture—all requiring immediate surgical intervention 1, 4, 5

Documentation Requirements

• Document the clinical findings indicating pregnancy and need for urgent cesarean section 1
• Document the assessment of the patient's capacity, including factors impairing it (pain, anxiety, denial) 1
• Document consent obtained from the parent/guardian 1
• Document the urgency of the situation and why delay would increase maternal/fetal risk 1, 2