Termination Of Pregnancy

You are the practitioner in charge of a short stay busy surgical ward.

Karen, a 19yr old , single, university student has been admitted to the ward at 8am following referral the previous day from her G.P.,  to undergo a termination of pregnancy at 11 weeks gestation.

Karen became pregnant following a one night stand, due to a condom break. Karen is 1 year into a 3yr degree programme studying law. Karen is a diligent and applied student, however she also has a history of anxiety and depression and takes medication for this. 

It was felt, by two independant Drs, that Karen's request for termination of her pregnancy would cause less damage , psychologically, interms of her wellbeing, than sutaining the pregnancy to full term. Both doctors involved have signed the required certification to this effect. (nhs.uk)

Karen has not attended a pre-assessement clinic prior to her admission. Therefore , the  surgical consent form for this procedure has not been signed. Neither has Karen been spoken to by a surgeon in outpatients, prior to her arrival on the ward. However, the duty dr on call, the night before , has already written up a precription of Cervagem 1mg pessary, to be administered to Karen, vaginally, 3 hours pre-operatively. Cervagem is a prostaglandin which softens and dilates the cervix, prior to intra-uterine procedures, in pregnant patients, in the first trimestar of pregnancy (medicines.org.uk).

Karen is scheduled to go second on the morning list for surgery, starting at 9am, behind a patient who's surgery will take approximately 90 minutes.

You ring the surgeon repsonsible for Karen's care (at 8.10 a.m.) and inform him that Karen has been written up for Cervagem but that there is no consent form signed.

The surgeon, who was late arriving and who is already scrubbed in theatre ( and not wanting to prevent any delays on his morning list) advises you, in no uncertain terms, to go ahead and give the Cervagem at 8.15 am and he will get the form signed in the anaesthetic room, in between patients, when Karen is escorted down to theatre. The house officer for surgery is also tied up on other duties and can not attend to give informed consent on the surgeons behalf.

You are concerned that Karen has not received informed consent regarding the risks of either termination of pregnancy or of receiving Cervagem prior to surgery, which can result in cramping, bleeding and spontaneous abortion (medicines.org.uk). if she canges her mind before termination, there is a high risk she will miscarry inevitably following administration of Cervagem. Neither are you sure of any contra-indications to administering Cervagem as Karen's medical notes have not yet arrived on the ward from the medical records dept.

You are unhappy about giving the pessary without informed consent, and in case Karen changes her mind pre-op . You also want to check for contra-indications. You are also concerned that if you dont give the pessary, Karen will not be able to recieve her surgery, which will upset her,  and this will also mean that the theatre list order will have to be changed around which will upset the surgeon as well as other patients involved.

What would you do ?