CLINICAL & TEACHING CASES OBSTETRICS & GYNECOLOGY.

Transcription

1 CLINICAL & TEACHING CASES OBSTETRICS & GYNECOLOGY

2 APGO COPYRIGHT The APGO Medical Student Educational Objectives, 8th edition, may be utilized as follows: 1. Faculty/residents/students /institutions may purchase hard copies for personal and general student use. The book may be photocopied for teaching purposes, but may not be retyped, altered or otherwise manipulated in any way. APGO must be acknowledged in all photocopied material. 2. The online Objectives may be printed out, copied and utilized as is, but may not be retyped, altered or otherwise manipulated in any way. APGO must be acknowledged in all photocopied material. 3. The PDF outlines may be printed out and used as is, but may not be retyped, altered or otherwise manipulated in any way. APGO must be acknowledged in all photocopied material 4. The online cases in Word may be manipulated to suit faculty purposes. APGO need not be acknowledged.

3 TABLE OF CONTENTS / LINKS TO INDIVIDUAL CASES 1. History 2. Examination 3. Pap Smear and Cultures 4. Personal Interaction / Communication Skills 5. Legal Issues / Ethics in Obstetrics & Gynecology 6. Preventive Care and Health Management 7. Maternal-Fetal Physiology 8. Preconception Care 9. Antepartum Care 10. Intrapartum Care 11. Immediate Care of the Newborn 12. Postpartum Care 13. Lactation 14. Ectopic Pregnancy 15. Spontaneous Abortion 16. Medical & Surgical Conditions in pregnancy 17. Preeclampsia-Eclampsia Syndrome 18. Isoimmunization 19. Multifetal Gestation 20. Fetal Death 21. Abnormal Labor 22. Third-Trimester Bleeding 23. Preterm Labor 24. Premature Rupture of Membranes 25. Intrapartum Fetal Surveillance 26. Postpartum hemorrhage 27. Postpartum Infection 28. Anxiety and Depression 29. Postterm Pregnancy 30. Fetal Growth Abnormalities 31. Obstetric Procedures 32. Contraception and Sterilization 33. Abortion 34. Vulvar and Vaginal Disease

4 35. Sexually Transmitted Infections & Urinary Tract Infections 36. Pelvic Relaxation & Urinary Incontinence 37. Endometriosis 38. Chronic Pelvic Pain 39. Disorders of the Breasts 40. Gynecological Procedures 41. Puberty 42. Amenorrhea 43. Hirsutism and Virilization 44. Normal and Abnormal Uterine Bleeding 45. Dysmenorrhea 46. Climacteric / Menopause 47. Infertility 48. Premenstrual Syndrome & Premenstrual Dysphoric Disorder 49. Gestational Trophoblastic Neoplasia 50. Vulvar Neoplasms 51. Cervical Disease and Neoplasia 52. Uterine Leiomyomas 53. Endometrial Carcinoma 54. Ovarian Neoplasms 55. Sexuality and Modes of Sexual Expression 56. Sexual Assault 57. Domestic Violence

5 UNIT ONE: APPROACH TO THE PATIENT 1. History 2. Examination 3. Pap Smear and Cultures 4. Personal Interaction / Communication Skills 5. Legal Issues / Ethics in Obstetrics & Gynecology 6. Preventive Care and Health Management

6 TEACHING TOOL 1 History This tool is designed to help the teacher lead an interactive session during which the students collectively develop a history taking format they can practice and internalize throughout the rotation. It is geared to taking a complete gynecologic history. Approximate duration: 60 minutes Resources needed: Large blackboard or erasable board vs. 2 to 3 flip charts Suggested curricular timing: First day or week of the rotation Rationale for inclusion in the curriculum: 1. History taking gets little formal curricular attention 2. It is a skill students must have 3. It is a skill that students can actually do, giving them a legitimate role on the health care team and building self-esteem 4. Opportunities to record things in charts is often limited 5. Many institutions have adopted pre-printed history check-lists into their formal medical records, encouraging students to become passive box checkers, rather than active information gatherers. In attempts to be concise, these forms often are poorly organized and leave little room for the students to record the patient s actual story. QUESTION 1: What is the first thing that gets recorded in a patient s history? ANSWER: The chief complaint. QUESTION 2: Outside of prenatal care, why do patients come to see an obstetrician-gynecologist? ANSWER:

7 Going around the room, the students create a list of around reasons girls and women seek gynecologic care. It helps set the stage for what they will be expected to learn the rest of the rotation. Their list typically includes: Annual exams Abnormal Pap smears Missed periods Heavy periods Painful periods Bleeding between periods Irregular periods Needs contraception Contraceptive complaints Pelvic Pain Dysmenorrhea Dyspareunia Vaginal discharge Vaginal itching Vaginal odor Ovarian cysts Menopause Infertility Pre-conception counseling STD checks Vulvar pain Vulvar lesions Breast pain Breast masses Postmenopausal bleeding Leiomyomata Bartholin s duct cysts Pelvic prolapse Urinary incontinence Post-operative care Wound infections Sexual assault QUESTION 3: What comes next in the history? ANSWER: The HPI. Indicate that each item they have listed has its own unique HPI. Describe what you want to hear at the beginning of every HPI, i.e. The patient is a 26 year old gravida X para Y with a last menstrual period on DATE here today for... Introduce helpful mnemonics, i.e. An Alphabet of Pain for the HPI P = Pain Q = Quality R = Region and radiation S = Severity T = Timing U = Undiagnosed? V = Vomiting and other associated symptoms W = What makes it better /worse OR, the ten B s of the post-partum visit

8 Bladder Bowel Bottom (episiotomy/lacerations) Bleeding (lochia /periods) Breasts Blues Birth control Boinking (OK-not technically acceptable, but it starts with a B) Baby (doing well?) Beaten/battered QUESTION 4: What is the next component of the history during this rotation? Answer: The past ob-gyn history Then present this to the students in the format and order you want them to collect and recorded during the rotation. QUESTION 5: What are the next components of the history that you will need to collect? Answer: Record these on the board in the order you want them collected and presented during the rotation: Past medical history Past surgical history Past psychiatric history Medications Medication allergies Family history Social history QUESTION 6: Small group activity. Break the students into the following four groups: 1. Past medical history 2. Past surgical history 3. Past psychiatric history 4. Family history Each group generates a list of ten common diseases or conditions that they can specifically ask their patients about in their assigned area. When all of the groups are done (5-10 minutes), they report these back to the group as a whole. Teacher records lists on the board.

9 Past Medical History - Lists typically include: Asthma Headaches IBD Allergies SLE GERD Seizure disorders URI s Hepatitis UTI s /pyelo Thyroid diseases CVA Hypertension DVT s/ PE Coagulopathies Diabetes Anemia Hypercholesterolemia From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include associated menstrual abnormalities, symptoms mimicking gynecologic conditions, potentially teratogenic therapies, high-risk pregnancy status, operative risks and impact on birth control decisions. Past Surgical History (non-gynecologic) - Lists typically include: Appendectomy Tonsillectomy Pressure equalization tubes ACL repair Breast biopsy Cholecystectomy Tooth extractions Thyroidectomy Hernia repair Correction of congenital anomalies Carpal tunnel release Plastic surgery From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include anesthetic complications, bleeding abnormalities, blood transfusions and post-operative intra-abdominal adhesions. Past Psychiatric History - Lists typically include: Depression Anorexia Bulimia OC disorder Psychosis Substance abuse Schizophrenia Anxiety disorders Suicidality Post-traumatic stress disorders From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include associated menstrual abnormalities, symptoms mimicking gynecologic conditions, therapy during pregnancy and lactation, birth control options and associations with prior abuse histories. Family History - Lists typically include:

10 Thyroid diseases Hypertension Diabetes Cancers Birth defects Coagulopathies CVA DVT s /PE Inherited anemias Chromosomal abnormalities CAD Hypercholesterolemia From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include inheritance patterns and impacts on personal health care decision-making. QUESTION 7: What do you routinely include in the social history? ANSWER: Alcohol use Illicit drug use Tobacco use Occupation Family and living situation Exercise Domestic violence If time permits, review the myriad impacts of smoking on reproductive health, i.e. Menstrual irregularity Premature menopause Infertility Miscarriage IUGR PROM PTL/PTD Cervical dysplasia/carcinoma Conclusion: Show the students the template they have collectively developed. Encourage them to practice using it over and over and over again so that it is completely internalized by the end of the rotation.

11 CLINICAL CASE 2 Examination Pelvic exam/annual exam At the end of this exercise the student will be able to: o Discuss the indications for pelvic exam o Understand the important components of the pelvic exam o Know the indications for additional exam of the anterior and posterior vaginal wall o Describe the importance of the rectal/vaginal exam. 52-year-old female comes in for annual gynecologic exam. She stopped menstruating two years ago and has experienced hot flashes and some insomnia. She, however, feels she is doing well and is not interested in HRT. Menarche was at age 13, menses were regular until last year prior to cessation of menses, but then she stopped and has had no more bleeding since that time. She had two pregnancies and two vaginal births; her children are 25 and 28. Her ROS is negative except for occasional loss of a small amount of urine in her aerobics class; if she is careful to empty her bladder prior to class, this isn t a problem. She is sexually active and needs to use a lubricant; however, sex is not painful. PMH is negative except for an appendectomy and breast biopsy, which was negative. She is married in a good relationship with no history of abuse and she exercises 3x/week in aerobics class or walks. She drinks a glass of wine with dinner and has never smoked or used illicit drugs. She drinks 3 glasses of milk/day. Family history is significant for mother with osteoporosis, sister with hypothyroidism and father with elevated cholesterol. Physical exam Normal appearing female 120/70, weight 130, height 5 5 Thyroid-WNL; Lungs- Clear; COR- RRR no murmur or gallops; Breast exam breasts are symmetrical with fibrocystic changes in the upper out section of each breast; no distinct masses are noted with evidence of small scar on R breast; Abdomen soft non-tender; Ext genitalia normal with evidence of midline scar consistent with vagina no lesions, slightly atrophic; Cervix appears to be WNL and Pap smear obtained. The speculum is taken apart and the lower blade of the speculum is used by placing in the vagina pressing downward to evaluate the anterior wall of the vagina. There is evidence of small cystocele and urethrocele, which descends slightly with Valsalva, but not to the introitus. There is no loss of urine during this maneuver. Bimanual reveals an

12 anteverted uterus with no adnexal masses palpate. In fact, the adnexa are not well appreciated, recto-vaginal exam is negative, confirms the vaginal exam and the stool is heme negative. You assure the patient that her exam is WNL. You begin counseling her re: lifestyle issues, encourage her to continue exercising regularly and perhaps add some weights to further decrease risk of osteoporosis. You counsel her regarding her needs for 1200 mg of calcium/day. Additionally, she should consider either a sigmoidoscopy or colonoscopy for colorectal screening. A mammogram is ordered, as well as screening cholesterol and thyroid screen. She is counseled regarding her Kegel exercises and need to keep bladder empty during exercise and to do Kegels to strengthen pelvic floor. She is sent out with a slip for cholesterol screening, thyroid screening, urinalysis and a set of three fecal occult blood cards. Discussion/teaching points The annual exam is more than just a breast exam and pelvic exam. It is the opportunity to assess a patient s overall health and health care needs. The same exam/laboratory tests are not done on each patient. One needs to consider age and risk factors when deciding what to do. This patient is 52-years-old; therefore, it is important to include colorectal screening and counseling in the exam. She should also have annual mammography, counsel regarding calcium intake and consider thyroid screening. Although SBE has not been shown to decrease morbidity or mortality from breast cancer, one should inquire if the patient does SBE and offer to teach her if she doesn t know how to do this. PE findings of urethrocele and mild cystocele are very common in older women who have had children. This is best detected on physical exam using a Sims speculum and having the patient Valsalva. This allows one to examine the movement and degree of prolapse of the anterior and posterior vaginal wall, as well as the cervix. A ureterocele, cystocele and rectocele do not necessarily require surgical repair. Mild symptoms of stress urinary incontinence, such as this patient reports, need to be addressed and usually respond well to behavioral measures, such as keeping the bladder empty during exercise and minimizing caffeinated beverages and to pelvic strengthening exercises or Kegels. On pelvic exam, the adnexa were not well appreciated, which is normal in postmenopausal women. Often the adnexa are not felt and, if they are palpated, might raise concern and necessitate further evaluation if thought to be enlarged. The rectal/vaginal is done to confirm the findings of the vaginal exam and is important in this age patient to evaluate for rectal cancers. Approximately 10% of rectal cancers can be detected with rectal exam. However, it is important to add fecal occult blood testing, which should not only be done at the time of the exam, but the patient also needs to do this at home on three consecutive bowel movements. This will increase detection of all colorectal cancers.

13 TEACHING CASE 3 Pap Smear and Cultures Student Handout Clinical Case: JA is a 22-year-old G0 female who presents for an annual exam. She had an abnormal Pap smear 4 years ago followed by a colposcopy but no biopsies were performed. Her follow-up Pap smears were normal and the last one was 2 years ago. She is currently sexually active with a new partner for the last 2 months, and has had four lifetime partners. She does not report any history of sexually transmitted disease. She is currently using birth control pills for contraception. She is just finishing her menstrual cycle and is spotting; her periods are regular without problems. Her review of systems is negative. She smokes one pack of cigarettes per week; she does not drink and states that she has occasionally used marijuana. She is a freshman in college and is majoring in business. Her vitals and physical exam are normal. Discussion Questions: 1. What are the different techniques available to obtain a pap smear? 2. In addition to performing a Pap smear, what cultures might you recommend for this patient, and how do you proceed in obtaining them? 3. How often does this patient need to undergo a Pap smear? 4. What risk factors does this patient have for cervical dysplasia and cancer? 5. If while performing the speculum exam, you notice a gross lesion on the cervix, what would your next step in management be? 6. What other counseling or advice you need to discuss with this patient? References: Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 1 Health Care for Women. Pages Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 2 Clinical Approach to the Patient. Pages

14 Pap Smear and Cultures Preceptor Handout The Pap smear is one of the most effective screening tests used in medicine today. Proper technique in performing the Pap smear and obtaining specimens for microbiologic culture will improve accuracy. The APGO Educational Objectives related to this topic are the following: A. Perform an adequate Pap smear* B. Obtain specimens to detect sexually transmitted diseases* C. Handle specimens properly to improve diagnostic accuracy* D. Provide an explanation to the patient regarding the purpose of these tests* *Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition

15 Pap Smear and Cultures Preceptor Handout Clinical Case: JA is a 22-year-old G0 female who presents for an annual exam. She had an abnormal Pap smear 4 years ago followed by a colposcopy but no biopsies were performed. Her follow-up Pap smears were normal and the last one was 2 years ago. She is currently sexually active with a new partner for the last 2 months, and has had four lifetime partners. She does not report any history of sexually transmitted disease. She is currently using birth control pills for contraception. She is just finishing her menstrual cycle and is spotting; her periods are regular without problems. Her review of systems is negative. She smokes one pack of cigarettes per week; she does not drink and states that she has occasionally used marijuana. She is a freshman in college and is majoring in business. Her vitals and physical exam are normal. Discussion Questions: 1. What are the different techniques available to obtain a pap smear? a. Discuss conventional Pap smear and Thin Prep: Both collected from the endocervical canal and transformation zone with spatula and cytobrush. Do not use any gel prior to performing the Pap smear. b. Thin prep has a higher sensitivity rate c. Discuss the importance of properly labeling specimens and sending off to promptly to the lab. 2. In addition to performing a Pap smear, what cultures might you recommend for this patient, and how do you proceed in obtaining them? a. Since the patient is sexually active with a new partner, you should offer her screening for sexually transmitted diseases including performing endocervical cultures or DNA probe for gonorrhea and Chlamydia. b. After performing the Pap smear, you wipe any excess cervical mucous and you insert the cotton swab to collect the cultures or the DNA probe in the endocervical canal.

16 3. How often does this patient need to undergo a Pap smear? a. Patients who have had an abnormal Pap smear previously, will need more frequent Pap smears based on the actual abnormality. For this patient, since it appears that she had normal follow-up, she needs to continue to have annual Pap smears assuming this one is normal. b. For monogamous patients who have had 3 normal Pap smears in a row, may space out the Pap smears to once every 2-3 years. 4. What risk factors does this patient have for cervical dysplasia and cancer? a. Multiple partners, sexual activity at an early age, history of abnormal Pap smear, smoking. 5. If while performing the speculum exam, you notice a gross lesion on the cervix, what would your next step in management be? a. Any gross lesion on the cervix will need to be directly biopsied as Pap smears have a false negative rate and cervical cancer might be missed. 6. What other counseling or advice you need to discuss with this patient? a. Discuss the importance of cervical cancer screening guidelines b. Discuss the importance of safe sex practices References: Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 1 Health Care for Women. Pages Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 2 Clinical Approach to the Patient. Pages

17 CLINICAL CASE 4 Personal Interaction and Communication Skills A 30-year-old female returns to the busy hospital clinic to get the results of her Pap smear. She has had a Pap smear every other year since age 20 all with normal results. Reviewing her chart, you see that she has been married for three years and has no children. She smokes two packs of cigarettes a week and is currently on oral contraceptives. She has no history of sexually transmitted diseases and appears to have a very conservative sexual history. Your supervising resident has been rushing from room to room and is now heading your way. Upon questioning, you explain to the resident that you understand the diagnosis and the next course of action. You enter the room and the patient is sitting in the chair. With both of you standing in front of the patient, the conversation between the resident and the patient is as follows: Resident: Hi, I m Dr. Jones and this is, one of our medical students. Patient: Hello Resident: (Full eye contact with the patient) As you know, we always have patients return to get the results of their Pap smear when things don t turn out as well as we would like. Patient: (Complete silence; looks concerned) Resident: (Speaking rather rapidly, steps back slightly, crosses arms, maintains eye contact) In your case, the results show HGSIL that means a high-grade squamous intraepithelial lesion. Patient: (Remains silent; squirms a little in her chair; now looks frightened) Resident: While I can t say exactly what caused this result, I can tell you that several factors can play role, including smoking, oral contraceptive use, experience with multiple sexual partners and, of course, having a male partner with multiple consorts. Patient: (Mutters while staring at the floor) I didn t know that. Resident: (Maintains eye contact, except for glancing at you a couple of times) Our standard protocol is to have a colposcopy with endocervical curettage and directed biopsies as indicated. There really isn t anything to worry about. On your way out, please stop at the front desk to arrange your appointment. Of course, if you have any questions after you get home, please feel free to call the clinic. (Looking at the clock on the wall), I m sorry I have to run, but we have a very full clinic this morning. Patient: (Looking both upset and puzzled) OK, doctor. The resident glances at you and leaves the room. You quickly assess what you need to do next.

18 Diagnosis/Management The table below is an evaluation of how well the resident interacted with this patient. Look closely at this evaluation and determine whether you agree with it. If not, how would you evaluate the interaction? In other words, how would you diagnosis the interaction and what would be your management plan for such an interaction? Skill Evidence in Exchange Performed Skill Y/N Establish rapport Introduced self and Yes medical student Informed patient of the Told her of HGSIL Yes clinical diagnosis Gave reasons as to Told patient several Yes possible etiology for clinical outcome (educated patient). etiologies that are epidemiologically related to HGSIL Open door for further Explained she could call Yes questions Informed the patient of management steps Worked with other members of health team the clinic anytime Asked her to schedule an appointment after telling her what needs to be done Implied clinic personnel could handle her questions Yes Yes To help you with your decision-making, consider the follow items: 1. How do you think the resident would answer you if you asked how the visit with this patient went? In other words, what do you think would be the resident s perception of this conversation? 2. What do you believe would be the patient s perception of this conversation? 3. Given the setting and atmosphere, would you approach the patient differently? 4. What was done to establish rapport with the patient? Could more have been done? 5. What can you glean from the patient s body language and from what she said or, perhaps, didn t say? 6. Did the resident treat the whole patient? 7. While what the resident said may be accurate, what impact might it have on the patient and why? (Suggest you take it comment by comment). If you had to evaluate this information exchange, what would be your criteria? Construct a new table with your criteria and apply it to this case scenario. Now that you have thought all of this through, what would you do if you were the medical student who has been left alone with the patient when the resident exited?

19 Teaching points: 1. This quotable quote from Quotes in Medicine on American College of Physicians-American Society of Internal Medicine Web site ( says much about the importance of communication. The most important difference between a good and indifferent clinician lies in the amount of attention paid to the story of a patient. Farquhar Buzzard 2. Effective communication between physician and patient is similar to communication between good friends or partners. This statement can be a discussion catalyst among students. Some of the Do s for effective communication in both cases are: Use I statements to express yourself (rather than saying we or you ) Be specific not only with medical information but with feeling type comments Show respect, warmth and caring Be genuine Be an active listener Maintain eye contact Give feedback this includes repeating or paraphrasing what the patient (or friend/partner) has said so both of you know what was really said Some of the Don ts for effective communication in both cases are: Don t assume you know what your patient (friend/partner) is thinking Don t use yes/no questions unless they are necessary Don t use labels (especially cultural stereotypes, assumptions) Don t act disinterested or be impatient Don t overload the patient (friend/partner) Students can generate these and additional points and apply them to the case scenario.

20 TEACHING CASE 5 Legal and Ethical Issues in Obstetrics and Gynecology Student Handout Clinical Case: A 33 year-old G2P1 Caucasian patient at 33 weeks gestation presents to your office for her scheduled prenatal visit. She reports no problems. Her psychosocial history is unremarkable. Her prior pregnancy resulted in a cesarean delivery with a transverse incision. There were no complications associated with the delivery. Her physical examination reveals normal blood pressure and weight. Fundal height, fetal position, and heart rate are unremarkable. Her diagnostic test results show Hgb: 12.4 g/dl; WBC: 11,000; Urinalysis: negative for bacteria and leucocytes; and urine drug screen: negative. Discussion Questions: 1. What would you tell this patient regarding her options for delivery? 2. What are the underlying ethical principles in informed consent? 3. What is the role of the physician in informed consent? 4. What is the role of the patient? 5. What topics might be included in an informed consent at this time? 6. What should be done if the patient declines a trial of labor after a history of lowtransverse c-section? References: Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 2 Ethics in Obstetrics and Gynecology. Pages Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 1 Practice Management and Ethics in Obstetrics and Gynecology. Pages 3-8. Chapter 5 Clinical Performance Improvement: Assessing the Quality and Safety of Women s Health Care. Pages Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies (4 th ed.). Philadelphia: Churchill-Livingstone, pp ,

21 Legal and Ethical Issues in Obstetrics and Gynecology Preceptor Handout Rationale: Legal obligations to protect patients interests are effective only if understood and applied. Recognizing and understanding the basis of ethical conflicts in obstetrics and gynecology will allow better patient care and prevent critical errors in treatment planning. The APGO Educational Objectives related to this topic are the following: A. Explain the issues involved in informed consent B. Demonstrate the role of confidentiality in clinical activities C. List the local laws requiring the reporting of suspected child abuse and domestic violence D. Discuss the legal and ethical issues in the care of minors E. Describe issues of justice relating to access to obstetric- gynecologic care F. Explain the basis of ethical conflict in maternal-fetal medicine G. Discuss ethical issues raised by induced abortion, contraception and reproductive technology *Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition

22 Legal and Ethical Issues in Obstetrics and Gynecology Preceptor Handout Clinical Case: A 33 year-old G2P1 Caucasian patient at 33 weeks gestation presents to your office for her scheduled prenatal visit. She reports no problems. Her psychosocial history is unremarkable. Her prior pregnancy resulted in a cesarean delivery with a transverse incision. There were no complications associated with the delivery. Her physical examination reveals normal blood pressure and weight. Fundal height, fetal position, and heart rate are unremarkable. Her diagnostic test results show Hgb: 12.4 g/dl; WBC: 11,000; Urinalysis: negative for bacteria and leucocytes; and urine drug screen: negative. Discussion Questions: 1. What would you tell this patient regarding her options for delivery? Trial of labor for a vaginal birth after a c-section (VBAC) Cesarean delivery 2. What are the underlying ethical principles in informed consent? Autonomy or self-determination the patient has the ultimate say Rational decision-making requires disclosure of information by both the physician and the patient 3. What is the role of the physician in informed consent? Establish a relationship conducive to the sharing of information and trust Be certain the patient (and when appropriate her partner) is well-informed Ensure the patient has, under ordinary circumstances, reasonable time to think about the information provided by the physician Be open to questions from the patient and the patient s partner Document the process as well as the decision 4. What is the role of the patient? To participate in the decision-making process To provide accurate and complete information To ask questions