The Ethics of Obstetric Care

Hyderabad, INDIAWebsite :

www.fernandezhospital.comAll India Congress of Obstetrics and Gynaecology,

19.1.2013, Mumbai

Dr. Evita Fernandez

Ethical principles and virtues should be

understood to apply to ALL physicians,

regardless of their personal, religious and

spiritual beliefs

ObstetricsThe branch of medicine

that specializes in care of women before, during and after childbirth.

Ethical Dimensions Unique to Obstetrics

Two inter-woven patients – interest may be at odds

Vulnerability of pregnant woman undergoing tests and procedures

Pregnant woman’s autonomy and physician’s judgement

Principles

1 Beneficence2 Nonmaleficence

3 Autonomy4 Justice

Beneficence

Best interests of the patient

Good over harm

Women who get pregnant should have the basic human right

of humane and evidence based

maternity care

It is NOT about the right to give birth

It is about the right to receive appropriate care when you do.

Appropriate Care

The right to information and

informed decision making

Informed Consent

Disclosure

Comprehension

Free consent

Communication

Justice

The fair distribution of health resources and

the decision of who gets what treatment

i.e. fairness and equality

All women should have support throughout labour

and birth.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth.

Cochrane Database of Systematic Reviews 2007

Support in Labour

Spouse / Partner

Family members

Midwife / student trainee

* Doulas

Single Most Important Intervention

The need for analgesics Rate of oxytocin Instrumental deliveries Caesarean sections 5 min APGAR score of < 7

“They expose you, they shave you, they cut you, they leave you alone

And don’t come when you call,and they won’t allow

your relatives to be with you”

Pauline Kolenda, birth in a hospital / village, India

Obstetric Violence(Venezuela)

1 Untimely and ineffective attention of obstetric emergencies

2 Forcing the woman to give birth in a supine position with legs raised

3 Impeding the early attachment of the child with his / her mother

4Altering the natural process of a low-risk delivery by using acceleration techniques without obtaining voluntary expressed and informed consent

5 Performing a C Section that is unnecessary

1 Untimely and ineffective attention of obstetric emergencies

2 Forcing the woman to give birth in a supine position with legs raised

3 Impeding the early attachment of the child with his / her mother

2Forcing the woman to give birth in a supine position with legs raised

Obstetric Violence(Venezuela)

Pain of Indignities

Enemas

Shaving of pubic hair

Lying flat on the back

Legs in stirrups for hours

Lack of privacy

Justice

The fair distribution of health resources and

the decision of who gets what treatment

i.e. fairness and equality

Newborn carefacilitating early bonding

Obstetric Violence(Venezuela)

1 Untimely and ineffective attention of obstetric emergencies

2 Forcing the woman to give birth in a supine position with legs raised

3 Impeding the early attachment of the child with his / her mother

3Impeding the early attachment of the child with his / her mother

Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.

Early skin-to-skin contact for mothers and their

healthynewborn infants

The Benefits of Early Skin to Skin Contact

Positive effects on breastfeeding (OR 1.82) Improved maternal bonding Infants cried for a shorter length of time Better cardio-respiratory function No adverse effects were found

Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.

Human Rights in Childbirth

Birthing women have a fundamental

human right to choose the circumstances

in which they give birth.

Nonmaleficence

First, Do no harm(Primum non nocere)

Obstetric Violence(Venezuela)

4

Altering the natural process of a low-risk delivery by using acceleration techniques without obtaining voluntary expressed and informed consent

5 Performing a C Section that is unnecessary

4

Altering the natural process of a low-risk delivery by using acceleration techniques without obtaining voluntary expressed and informed consent

Interventions that may cause harm

Induction of labour Oxytocin drip Rupture of fore-waters Repeated vaginal examinations

Autonomy

The right to choose

and follow

one’s own plan of

life and action

Caesarean Delivery upon Maternal Request (CDMR)

... in the absence of any

specific medical indication

National Institute of HealthMarch 2006

“Insufficient evidence to issue a recommendation concerning

the relative safety of planned Caesarean births

and called for further study”

FIGO : Ethically not justified

ACOG : Not recommended for

women “desiring several children”

Consent for Caesarean Section should be requested AFTER providing evidence based information in a manner that respects the

woman’s dignity, privacy, views and culture, apart from the clinical consideration.

NICE Guidelines, Nov. 2011

International Caesarean Awareness

Network (ICAN)

- Unethical and immoral

Caesarean Delivery upon Maternal Request (CDMR)

www.ican-online.net

Proponents of natural births- Undermines a woman’s confidence

in her own body and minimizes her participation in the birthing practices

Caesarean Delivery upon Maternal Request (CDMR)

CDMR : Potential Risks

↑ Neonatal respiratory morbidity

Potential surgical complications

Future pregnancies – abnormal placentation

– uterine rupture

CDMR : Potential Benefits

Convenient time

Lowered risk of haemorrhage

↓ Neonatal injury

Ethical Question : CDMR

Do these surgeries represent

Am. Fam. Med 2006;34 : 265-8

Patient

Choice

Demand

Request

Talking Points for Informed Consent on CDMR

Do not recommend / offer Enquire WHY / EDUCATE / ADDRESS MYTHS Be explicit in discussing risks / benefits Risks to future pregnancies Refer to another health care provider

ACOG, Obstet Gynecol 2007;110 : 1501-4

A woman giving birth is the final decision maker in the birth process.

Doctors, midwives and others can inform, advise and support.

Informed Consent

Disclosure

Comprehension

Free consent

Communication

The state of pregnancy

does NOT deprive a woman

of her right to decide what

should happen to her body

Birth Plan

What are your wishes during a normal labour

and delivery ?

How do you hope for your baby to be treated

immediately after birth

BIRTH PLANMode of delivery

Gestational age

Epidural

Support in labour

Episiotomy

Breast Feeding

Only one rule in medical ethics need concern you

– that action on your part which best conserves the interests of your patient

– Martin H. Fischer