Lead-in: For each of the following scenarios, please select the most applicable medico-legal principle from the option list. Each option can be used once, more than once, or not at all. Option List :
B. Fraser (Gillick) competence
J. Bolam test
L. Montgomery ruling.
1. A young 19-year-oldPrimi refuses to come in to hospital despite breaking waters at 30 weeks. A community midwife later visits her at home and confirms it to be PPROM. However, she refuses antibiotics, steroids and further monitoring saying that ‘God has willed her to stay at home’.
2. A 15-year-old has come to her GP surgery requesting contraception as she intends to become sexually active. She doesn’t want her parents to know about this as they are devout Catholics. The GP evaluates her to be competent in understanding his advice and prescribes her a 3-month pack of COC.
3. A 40-year-old lady with severe vaginismus is admitted with regular uterine tightening. She has a terrible fear of labour and delivery. Despite several attempts she refuses internal examination. However, when there was a bradycardia the doctor forcibly does an internal examination and notes her to be fully dilated.
4. A 25-year-old lady comes in to the triaging unit with a history of reduced fetal movements over past 2 days. She is a smoker and had type 2 diabetes which has been poorly controlled. This baby is macrosomic at 96th centile and she is currently 37 weeks pregnant with previous 2 CS in the background. When the midwife puts her on CTG, she notices a pattern of reduced variability which she forgets to escalate as it is a busy triaging unit. After 2 hours on the monitor there is sudden fetal bradycardia and by the time a decision for delivery is undertaken and the baby is born at least4 hours have lapsed. The baby is born with poor cord blood gases and needs admission to NICU with suspected HIE.
5. While doing an audit on cervical smears done over the past 2 years, the team accidentally stumble on a report with grade 3 CIN which has been accidentally reported as normal.The team hold ahigh-level executive meeting as to whether they should be whistleblowing this event.
6. A maternity unit has been under scrutiny by the CCG due to their high rates of HIE,there has been a recent case in their unit where a lady with type 2 diabetes withmacrosomic baby had a shoulder dystocia following IOL at 38 weeks. The baby had severe HIE and extensive Erb’s palsy. The lady was never given an option of elective C-section from the outset and this angered the lady and made her complain to the Ombudsman.
7. A young 15-year-old girl has been blue lighted to A&E as she suddenly collapsed and turned pale while shopping with her friend in a shopping mall. In A&E although she is conscious, she is noted to be in shock. Her Urine pregnancy test is positive and a FAST scan reveals severehemoperitoneum. Ectopic pregnancy is suspected, and preparation is made to take her to theatre. The girl however refuses surgery as she is worried her parents will come to know about her pregnancy.
8. A 23-year-old who is currently 6 weeks pregnant is having trouble with her marriage. She has contacted TOP services for ending her pregnancy. The husband who is unaware of the wife’s decision, demands that the doctor has a look into her records to see what the wife is planning to do with her pregnancy as he feels that he has the rights, as a father.
9. A 30-year-old lady who has been tested to be positive for HIV and has a high viral load has refused Anti-retroviral treatment. Following birth, she intended to breast feed the baby despite knowing that it had a high risk of passing infection to the baby. Social services plan to confiscate the baby from the mother as she has high risk behaviour and the well being of the child has been compromised.
10. While doing a laparoscopic surgery for endometriosis a large endometriotic nodule is noted on the sigmoid colon. The surgeon is a general gynaecologist. As the patient hasn’t had her bowel prepared and there is no colorectal surgeon around to help him with the surgery, he prefers not to remove the nodule as there was high risk of injuring the colon.
For each of the following clinical scenarios please select the most appropriate method of termination of pregnancy from the list of options above. Each option may be used once, more than once or not at all.
Option List :
A. Cannot offer termination under clause E
C. Induction of labour with mifepristone and prostaglandins
D. Potassium chloride feticide prior to induction of labour with mifepristone and prostaglandins
E. Selective feticide using potassium chloride
F. Selective feticide using umbilical cord occlusion
G. Surgical evacuation
H. Manual vacuum aspiration.
I. USG guided suction evacuation
11. A woman is diagnosed to severe hydrops at 22+6 weeks secondary to cystic hygroma. A karyotyping done from amniocentesis sample reveals Trisomy 18.
12. A lady with MCDA twins, with one twin detected to have skeletal dysplasia of a severe type. The other twin is found to be normal. The parents are keen on terminating the unhealthy twin but want to keep the healthy twin.
13. A 20-year-old girl has been sexually abused by her 40-year-old uncle. She doesn’t realise she is pregnant until 25 weeks.
14. An asylum seeker has been booked late in pregnancy. She has her first scan at 28 weeks when anencephaly and severe polyhydramnios is detected.
15. A lady at 20 weeks with low lying placenta comes to A&E with life threatening bleeding. The bleeding is understood to be from the placental site. She has lost 2 litres so far and is continuing to bleed further.
16. On a growth scan at 28 weeks a couple are told about cleft lip in the baby. The couple request for termination.
17. A 42-year-old who conceived following her 6th attempt at IVF has been diagnosed with limb body wall complex in the baby at 23 weeks. The couple are shattered. They have been advised with termination.
18. A 38-year-old pregnant for the first time had declined first trimester screening for chromosomal defects. However, during a detailed scan at 21 weeks, hypoplastic left heart and omphalocele has been detected. Due to strong suspicion of chromosomal defects the lady has been offered another chromosomal testing which was accepted this time. The results of amniocentesis came back at 22+3 weeks as Trisomy 13.
19. A 30-year-old had a medical TOP in her first pregnancy for social reasons at 9 weeks. However, she continued to bleed on and off for 2 weeks thereafter. A urine pregnancy test done 3 weeks later was still positive. She came back to the hospital where a repeat scan suggested RPOC of 4 cm. She is a very anxious lady and didn’t tolerate a speculum examination.
20. A P2 with previous 2 normal births unfortunately had an incomplete miscarriage at 14 weeks. She started bleeding after expulsion of fetus. Hence was taken to theatre where placental bits were delivered. Following discharge 3 days later she presented with another bout of bleeding. Scan at this point suggested retained pregnancy products.
Lead in: For each of the questions below, choose the most appropriate answer from the list of options above. Each option may be used once, more than once or not at all.
Option List :
C. Less than 1:100
H. Reduces incidence of bowel and vascular trauma only
I. Reduces incidence of vascular trauma only
J. Reduces incidence of bowel trauma only
L. A person in family
M. A person in village
N. A person in small town
O. A person in large town
21. Need for emergency hysterectomy during a routine caesarean section
22. Risk of developing blood clots following caesarean section
23. Hernia at entry site during a diagnostic laparoscopy.
24. Risk of bowel adhesion following a previous Pfannenstein incision.
25. Advantage of open entry during laparoscopy over closed entry technique