What is the most appropriate next step for a 32-year-old woman, gravida (number of times pregnant) 1, para (number of viable births) 0, at 42 weeks gestation, with spontaneous rupture of membranes, contractions, and a non-reassuring fetal heart rate tracing, who refuses emergency cesarean delivery despite understanding the risks of fetal asphyxia and death?

From the Guidelines

The most appropriate next step is to continue to engage in respectful dialogue with the patient, involving a multidisciplinary team including an ethics consultant, while preparing for an emergency cesarean delivery if the patient changes her mind. Despite the clear medical indication for immediate cesarean delivery due to signs of fetal distress (absent variability and recurrent late decelerations), the patient has the legal and ethical right to refuse any medical procedure, even when this refusal may result in harm to the fetus. The medical team should ensure the patient fully understands the risks, including potential fetal death or neurological injury, but cannot override her autonomous decision. Documentation of the informed refusal is essential, including the patient's capacity to make decisions and her understanding of the consequences. Throughout this process, the team should continue fetal monitoring, provide supportive care, and maintain open communication with the patient, as she may reconsider her decision as the situation evolves. This approach respects patient autonomy while still providing the best possible care under the circumstances, as supported by the principles outlined in the Society for Maternal-Fetal Medicine consult series 1. Key considerations include:

• The high risk of adverse fetal outcomes associated with fetal growth restriction and abnormal fetal heart rate tracings, as discussed in the context of fetal growth restriction management 1
• The importance of shared decision-making and comprehensive patient counseling on neonatal morbidity and mortality, particularly in cases involving significant fetal risk 1
• The need for coordination of care between maternal-fetal medicine and neonatology services in high-risk pregnancies, ensuring that all parties are informed and prepared for potential outcomes 1

From the Research

Next Steps in Management

The patient has refused cesarean delivery despite being informed of the risks of refusing the procedure. The following are considerations for the next steps in management:

• The patient's refusal of cesarean delivery must be respected, as she has the right to make informed decisions about her care 2, 3.
• However, the fetal heart rate tracing shows significant abnormalities, including absent variability and recurrent late decelerations, which indicate a high risk of fetal asphyxia and death 4, 5.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that women be informed of the risks and benefits of cesarean delivery and that their decisions be respected 6.
• In this case, the patient's decision to refuse cesarean delivery must be carefully documented, and she must be closely monitored for any changes in her condition or the fetal heart rate tracing.
• The patient's care team should continue to provide her with supportive care and closely monitor the fetal heart rate tracing, while also respecting her autonomy and decision-making capacity.

Considerations for Vaginal Delivery

If the patient continues to refuse cesarean delivery, the following are considerations for vaginal delivery:

• The patient's cervix is 4 cm dilated and 25% effaced, which indicates that she is in active labor 2.
• The fetal heart rate tracing shows significant abnormalities, which increase the risk of fetal asphyxia and death during vaginal delivery 4, 5.
• The patient's care team should continue to closely monitor the fetal heart rate tracing and be prepared to intervene if there are any changes in the tracing or the patient's condition.
• The patient should be informed of the risks of vaginal delivery in this situation and should be closely monitored for any signs of fetal distress or other complications.

Documentation and Communication

The following are considerations for documentation and communication:

• The patient's refusal of cesarean delivery and her decision to proceed with vaginal delivery must be carefully documented in her medical record 2, 3.
• The patient's care team should communicate clearly and effectively with her about her condition, the risks and benefits of vaginal delivery, and any changes in her condition or the fetal heart rate tracing.
• The patient's care team should also communicate with other healthcare providers involved in her care, including obstetricians, anesthesiologists, and pediatricians, to ensure that everyone is aware of her condition and her decisions.