[Caesarean section in conflict with the patient's right to self-determination?]. / Een sectio caesarea tegen haar wil?

Competent patients have the right to refuse treatment and healthcare workers should acknowledge their wishes. In the Netherlands there are conflicting (constitutional) rights of the foetus and of mentally ill patients. This paper describes the legal and ethical problems in the case of a mentally ill patient at 37 weeks of pregnancy who refused an obstetric examination. The patient refused to cooperate and have her physical condition and mental status examined. Her refusal endangered the life of the foetus. The obstetrician decided to perform a caesarean section, even if this would be in conflict with the patient's right to self-determination. In these cases no legal framework exists for providing the best medical care. New legislation should be drawn up to prevent similar cases occurring in the future. If a caesarean section is in conflict with a patient's right to self-determination, it should always be performed as a last resort.

Perceived sleep quality is worse than objective parameters of sleep in pregnant women with a mental disorder.

OBJECTIVE: Disturbed sleep during pregnancy is associated with adverse obstetric outcomes and less mental well-being. In pregnant women with a mental disorder, who frequently suffer from sleep problems, it is unknown whether predominantly objective or subjective sleep quality is more affected. To clarify this, we compared objective and subjective parameters of sleep quality between patients and healthy controls during pregnancy. METHODS: This observational study was embedded in an ongoing study among pregnant women with a mental disorder at the department of Psychiatry of Erasmus University Medical Center Rotterdam, the Netherlands. We compared 21 pregnant women with a confirmed mental disorder with 33 healthy controls (gestational age, 23-29 weeks). To measure objective parameters of sleep quality, all participants continuously wore a wrist actigraph for 7 days and nights. Subjective sleep quality was retrospectively assessed using the Pittsburgh Sleep Quality Index (PSQI) and on a daily basis with the Subjective Sleep Quality-scale (SSQ). Differences in parameters of sleep between patients and controls were tested using a multivariate linear regression analysis adjusted for parity, gestational age, educational level, and employment status. RESULTS: Objective parameters of sleep quality and subjective sleep quality as assessed by the PSQI did not differ significantly between patients and controls. Daily sleep reports showed that, relative to controls, patients had a significantly worse average SSQ-score (5.2 vs. 7.6, adjusted ß = 0.12, 95%CI = 0.03-0.53, p < 0.01). CONCLUSIONS: Our exploratory study suggests that perceived sleep quality reported on a daily basis by pregnant women with a mental disorder is worse than the sleep quality as measured by wrist actigraphy.