A 37-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the emergency department with her husband for heavy vaginal bleeding. An hour ago, she started to have bright red vaginal bleeding that has increased to large clots over the past few minutes. The patient has had mild abdominal cramping and minimal fetal movement. She has received no prenatal care during this pregnancy. Blood pressure is 90/64 mm Hg and pulse is 102/min. When the patient is told that a pelvic examination needs to be performed, she becomes uncomfortable and appears nervous. The patient requests a female health care provider for the examination. However, only male health care providers are available at this emergency department for the next several hours. Which of the following is the most appropriate course of action?
The pelvic examination is intimate, and many women are uncomfortable or embarrassed by it and prefer a female examiner. Under most circumstances, this request should be accommodated whenever possible to respect patient autonomy:
Most patients presenting for a routine office visit (eg, routine prenatal visit) have nonemergent conditions; therefore, patients may be able to defer the examination or wait for the next available female provider.
However, in emergency situations, such as in this patient with heavy vaginal bleeding and maternal hypotension concerning for placenta previa or placental abruption, immediate evaluation with pelvic examination is required for diagnosis and management. Although a female health care provider is not available, every effort should be made to provide the same standard of care. Therefore, deferring the examination (eg, monitoring the patient only) or transferring the patient to another facility is inappropriate because it risks maternal-fetal morbidity and mortality (Choices B and E).
In both emergent and nonemergent situations, other alternatives should be explored to balance the need for timely and appropriate medical care with respect for patient autonomy and consent (ie, the right to accept or refuse medical care). One solution is asking whether the patient would agree to the examination with a female chaperone present. Regardless of patient or provider gender, having a chaperone present for sensitive portions of the physical examination (eg, breast, genitourinary, rectal) is becoming more commonplace.
(Choice C) This patient is an adult with capacity (ie, understands the risks, benefits, and alternatives to make an informed medical decision). Capable patients have the right to make their own treatment decisions. Therefore, obtaining consent from the patient's husband is inappropriate.
(Choice D) Performing a pelvic examination on a nonconsenting adult is coercion and/or assault, regardless of the emergent circumstances. This approach would also likely erode patient-provider trust and could worsen medical outcomes.
Educational objective:
Women who decline pelvic examination by a male health care provider when no female health care provider is available may be offered a female chaperone.