Refusal of emergency caesarean delivery in cases of non-reassuring fetal heart rate is an independent risk factor for perinatal mortality Rachel Ribak a , Avi Harlev b , Iris Ohel b , Ruslan Sergienko c , Arnon Wiznitzer b , Eyal Sheiner b, * a Faculty of Health Sciences, Joyce and Irving Goldman Medical School, Soroka University Medical Center, Ben Gurion University of the Negev, Be’er-Sheva, Israel b Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O. Box 151, Be’er Sheva, Israel c Department of Epidemiology and Health Services Evaluation, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel 1. Introduction While providing medical care for pregnant women, the medical staff are responsible for both the woman and her fetus [1]. The woman and the physicians are required to make decisions which have consequences on both the mother and her fetus. A mentally competent adult pregnant woman has the right to refuse medical intervention. This refusal may result in a negative impact on the child, leading to future disabilities or even death [2]. In the last decade, advances in medical technology have rendered the fetus more ‘‘visible’’ within the mother’s uterus, therefore contributing to the notion that the fetus is an independent patient [3]. The prevailing approach in the United States and in the United Kingdom is that a pregnant woman is under no legal duty to the health of her fetus; consequently, she cannot be compelled to do anything for the benefit of her fetus. The viable fetus has no rights, and the interest of the mother has higher priority over the interest of the fetus. As long as the life of the mother is not in danger, the court gives absolute deference to the decision of the woman [4]. However, a poor outcome to the fetus or to the mother is considered a catastrophe that is unacceptable from a public view, as well as in the medical community. A well- known extreme case that represents this view is Melissa Rowland’s case, in which the State of Utah charged Melissa Rowland with the murder of her stillborn fetus, because of her refusal for a caesarean delivery (CD) [5]. Refusal by pregnant women of consent for an urgent CD is a complicated situation. In a European survey that compared the attitude of obstetricians towards refusal to consent to emergency CD, the vast majority stated that they would continue to persuade the woman to consent to CD. Moreover, there was a small minority of physicians that stated that they would proceed with CD without a court order and without the woman’s consent [6]. In support of these physicians, it was found that a patient refusing any medical intervention in obstetrics had higher rates of pregnancy and labor complications in general and in perinatal mortality specifically [7]. Suspected fetal distress is the most common cause for emergency CD. Fetal heart rate (FHR) monitoring has been widely criticized lately: it is known to be associated with an increase in CD and instrumental vaginal delivery. Although it is a sensitive tool to European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 33–36 A R T I C L E I N F O Article history: Received 16 December 2010 Received in revised form 9 March 2011 Accepted 14 April 2011 Keywords: Adverse neonatal outcome Non-reassuring fetal heart rate Perinatal mortality Refusal of caesarean delivery Refusal latency A B S T R A C T Objective: To assess pregnancy outcome in women who initially refused medically indicated caesarean delivery (CD) in cases of non-reassuring fetal heart rate (FHR) patterns. Study design: A retrospective cohort study, comparing patients who refused and did not refuse caesarean delivery (CD) due to non-reassuring FHR tracings, was conducted. Deliveries occurred between the years 1988 and 2009 in a tertiary medical center. Multivariate analysis was performed to control for confounders. Results: Out of 10,944 women who were advised to undergo CD due to non-reassuring FHR patterns, 203 women initially refused CD. Women refusing medical intervention tended to be older (30.6  6.9 vs. 28.29  6.1, P < 0.001) and of higher parity (46.8% vs. 19.9% had more than 5 deliveries; P < 0.001) as compared to the comparison group. Refusal of CD was significantly associated with adverse perinatal outcome. Using a multiple logistic regression model controlling for confounders such as maternal age, refusal of treatment was found as an independent risk factor for perinatal mortality (adjusted OR = 3.3, C.I. 95% 1.8– 5.9, P < 0.001). A non-significant trend towards higher rates of adverse perinatal outcome was found when refusal latency time was longer than 20 min (OR = 2, 95% CI 0.36–11.95; P = 0.29). Conclusion: Refusal of CD in cases of non-reassuring FHR tracings is an independent risk factor for perinatal mortality. ß 2011 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +972 8 6400774; fax: +972 8 6275338. E-mail address: sheiner@bgu.ac.il (E. Sheiner). Contents lists available at ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb 0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2011.04.008