Ms. A, a 24-year-old obese primigravida, was admitted electively for delivery due to being post-term (40 weeks + 9 days) without signs of labour. Induction of labour was initially planned aiming at spontaneous delivery. However, due to suspected macrosomia, she was scheduled for lower segment caesarean section operation. Ms. A, however, refused to undergo any medical procedures. Every attempt to undertake these procedures triggered panic attacks, which lasted 10 - 15 minutes/episode with palpitations, shortness of breath, light-headedness, near-fainting, trembling, and non-specific body aches. Ms. A was aware that her fear was out of proportion; but she was unable to control her anxiety.
Ms. A had developed intense fear of needles after repeated blood tests when she had dengue fever in childhood. She avoided all medical procedures since then. Throughout the pregnancy, she refused all antenatal blood investigations, vaginal examination, and psychiatric referral.
On the day of the scheduled operation, Ms. A was taught deep breathing exercise and given low dose oral midazolam of 3.75 mg after a difficult IV cannula insertion. General anesthesia with rapid sequence induction was planned for the operation. However, when she was already on the operating table, she became agitated, and refused facemask application for preoxygenation. She also changed her mind and refused to have the surgery.
A multidisciplinary case conference was convened including the obstetrics and gynecology, anesthetic, psychiatric, and legal team to discuss further management. The legal team pointed out that under prevailing laws, the patient had the right to withdraw consent for operation at any point before the procedure even though this would endanger the baby’s life. From the obstetric point, there was an increased risk of fetal compromise and intrauterine death due to prolonged pregnancy.
A second attempt to take her to the operation theatre (OT) also failed.
On 40 weeks + 13 days, intensive graded exposure therapy was conducted urgently and continuously for 3 hours. This stepwise exposure focused on preparing the patient to face her fear towards all medical procedures, specifically the fear of needle and blood prior to entering the OT. First, relaxation techniques such as muscle relaxation and deep breathing exercises were taught as coping mechanisms. Next, a fear hierarchy was established with the patient grading the stimuli using units of distress. Subsequently, she was exposed to the stimuli in stages, starting from the least feared. She would inform the therapist whenever panic symptoms occurred and practiced the relaxation techniques with guidance until she reached a state of serenity. During the session, the patient successfully reached the interchange zone (dirty/sterile) in the theatre.
Late that night the patient developed regular contractions indicating that she was in labour. On the next morning, at 42 weeks, the psychiatric team accompanied the patient from the ward to the OT using the same principles of graded exposure therapy. The patient was successfully taken to the OT and caesarean section was performed under general anesthesia. Mother and child were discharged well on the 3rd day post-op.
The patient is now on regular psychiatric follow-up, receiving cognitive behavioral therapy.